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Y� Y I qj•"T- p. .� - APPLICATION?'--OR PEftMIT ' SAN JOAQUIN L �ALMEALTH DISTRICT U" ` 1601 E. HAZELTOWAVE. STOCKTON, .CAS Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE IS2$Up�r°'; ,x �' .. (Complete in Tr,�plicatel r, � ' { k Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the.work herein described:This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and thl®]ies.an¢Regulations of-the San Joaquin Local Health District. r r} t Job Address �.�' City Ira'E PM ��. [Q f� _ C� Ef. Addressp-1) goo o_-7—ho I'- 7 "Phl 41 /5 Owner's Namea � Contractor's Name (-License No.- Piiona TYPE OF WELL/PUMP:' NEW WELL ❑ WELL REPLACEMENT I& DESTRIJCTIdN PUMP INSTALLATION ❑ SYSTEM,REPAIR kir v DISTANCE TO NEAREST: SEPTIC TANK /C7 0 f SEWER LINES' . DISPOSAIL 00 ,' PRA U}1lE FOUNDATION AGRICULTURE WELL OTHER V kLL P17S/51I.M)'S,,T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC .TiO f/ ❑ Industrial - —13-Open Bottom ❑ Manteca Dia. of Well Excavahon y D1a of Well Casing ❑ Domestic/Private ,6&avel Pack ❑ Tracy Type of Casing C. r s� Speciflsat F. C�Q•� - 1 i7 Public ❑ Other ❑ Delta Depth of Grout Seal Ty a pf Grout laf G�1? ❑ Irrigation _L__�Approx. Depth �1❑ Eastern Surface Seal Installed by Repair Work Done Type'of Pump _5 tib"— H.P. State Work Bone 1 ��e �� 3 Well Destruction ' Well Diameter Sealing Material [top 50'1 — ` F' Depth Z Filler Material !Below 50') TYPE OF SEPTIC WORK: ' NEW,INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION 011\10 septRc-system permitEBd if public sewer is available'W in 200 feet.),' ' Installation will serve: Residence_ Commercial_ Other ,; "s' ° Number of living units: Number of bedrooms - ` Character of soil to a depth of 3 feet: Water table depth. SEPTIC TANK ❑ Type/Mfg Capacity No: Compartments t T PKG. TREATMENT PLT. ❑ Meth d'of Disposal's Distance to neo . Well Foundation Property.Line- LEACHING LINE ❑ Length of lines Total length/size FILTER BED Distance to nearest: Well =�>Foundation— Property I.+ne._ �� r SEEPAGE PITS ❑ Depth Size Number' SUMPS ❑ Distance to nearest: Well Foundation Property eine DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Jpaquin county&Anances, state laws, and rules and regulations of the San Joaquin Local Health District. _ Home owner or licensed-agent's signature certifies the following: "I certify that in the performance of the vr/orjc,fo{which thls permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of Cal-Ifornia."ContracfOW hiring'drl:b coi)tracting signature certifies the following: I certify that in the pitformance of the work for which this permit is issued,I shall.employ personssubject to rivorkman's compensa- tion laws of California." The applic ust ca for all required i cti Co F to drawing on arse side. F Signed x Title: b * D teM,, FOR DEPARTMENT USE ONLY-Ari, •'"' � Application Accepted by Date Pit or GrIl Inspection by Date Final Inspection by Date Additional Comments: - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 835 6385 f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave, P O foxtk, CA 91' 4 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. INFO CASH +EH 1324(REV.10/831 / �� , EH 14-28