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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 F HA EL T ON AVE., STOCKTON, CA Telephone (2og) 466-6781 PERMIT EXPIRES i YEAR FROM DATE ISSUED ` },:yT t0 : :gat i, 4' „ (C Application is hereby m oplete in Triplicate) ' - +ail ii',"t"�".,�; . made to the San Joaquin Local Health District for a permit to construct and/or ins made In compliance with San Joaquin Coun ` Local Health District. r � ' 4 �z Ftr!fLs ` ty Ordinance No. 549 for sewage or No. 1 tali the work herein described. This application is ,. 862 for well/pump and the•R4Ies and Regulations of the San Joaquin Job Address �� . . . —,, t City r {�— ., ;�• .k Owner's Name - f _ otPM Size_ aC`qC7 +f c4. Address ` / _7 � J Contractor `"FY y� Phone"-- ?'T TYPE OF WELL/PUMP: dress C�� tta a NEW WELL ❑PUMP I (�].4f/ Phone , WELL REPLACEMENT ❑ License No. 2G,~� DISTANCE TO NEAREST; SEPT TANK NSTALLATION E2SYSTEMREPAIR ❑ DES TRUCTION ❑ SEWER LINES OTHER ❑ FOUNDATION ,AGRICULTURE WELL DISPOSAL FLD-� PROP LINE y INTENDED USE OTHER WELL t T---- OF WELL PROBLEM AREA �� PITS/SUMPS ❑ Industrial L7 Open Bottom CONSTRUCTION SPECIFICATIONS ❑ Domestic/Private ❑ Mantica~ Dia. of Well Excavation El Gravel Pack ❑ Tracy Dia-`Of Well Casing ❑ Public ❑ Other Type of Casing 11 Irrigation Delta Depth of Grout Seal Specifications --- Approx. Depth E3 Eastern Surface Seal Installed by TVPe'of Grout Repair Work Done 11 / TYPe of Pump Well Destruction ❑ Well Diameter H.P. State Work Done Depth Sealing Material (top 50,) TYPE OF SEPTIC WORK; NEW IN5TALLATiON Filler Material {Below 50'} REPAIR/ADDITION ❑ .DESTAUC710N D Nv Installation will serye: Residence V '�` 4ti €" f septic system k.. ' , permitted if public sewer is Commerciall Other ti� aE +- ';' available within 200 feet.) l Number of living units: Number of,beirooms -�ChaFacter of soil to a depth of 3 feet: SEI? IC TANK b Water table depth O �YPe/Mfg�> •�� C�� PKd.TREATMENT PLT. ❑ Capacity a t7 b �:y• t � No. Compartments-"' 2- � h -�--'— Distance to nearest T s- Wellof, of DisF4unclation01 Mposal Property Lino LE G LINE ❑ No. & Length of lines ' L / FILTER $ED oW--Distance to neafestir lata lerigth/size kWel��-7� �. Foundation1 'It Property Line.1 i SEEPAGE PITS ❑ Depth G7 /"f SUMPS r Size3r= /�_.: �t a a;Distance to nearest: Well_� � Number , DISPOSAL PONDS ❑ Foundationroperty Line =�- ihereby certify that I have prepared this application and chat the'work`will,be `~ rules and regulations of the San Joaquin Local Health District. rrr `.>> ;it ; done in accordance with San Joaquin county ordinances, state laws, and Home owner or licensed agent's signature certifies-1he f&flowiri _ employ any person in such manner as to�become subject to workman's oompensat on laws oCalifornia."Contract ' certifies the followitfieng- Performance of the work fior which this permit is issued, 1 shall not F 9 'l c ify that in the performance of the work for which this permit is issuedI shall employ i ors hiring tion laws of California." g or sub-contracting signature. The applicant must c f € la Y Persons subject to workman's cpm it ins I' pensa s. Complete drawing on reverse side. Signed � '� � � Title:3 _�[ _ f Date; �"t FOR DEPARTMENT USE�ONLY } f Application Accepted by r Pit or Grout Inspection by' Date Area C5 s Date ` Fina!inspection by Additional Comments: Date k Stk 466-6783 L2 Lodi 369 3621 T ❑ Manteca Applicant- Return all copies to: Environmental H 823-7104- ❑ Tracy 836385 ealth Pe .7104 1601 E. Hazelton Ave., P.O. Box 2009 rStk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK# `_ CASH Ell CEIVED 13Y DATE 113-24(REV,t/a.5) [�. PERMIT`NO. " 11416 r -1