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3�7.L APPLICATION FOR PERMIT m^' SAN JOAO,UIN LOCAL HEALTH DISTRICT 'I ' ,.sa *ff ." .r 4rR` 1601 E. HAZE T ON AVE., STOCKTON, CA f Telephone 12091 466-6781 PERMIT EXPIRES'l YEAR FROM'DATE ISSUED {Complete In Tripllcate) 'I'f �w. T. - .. .t,; ,_`.� .:r, - '-,r - =..L�i,' rrs;i�' -''�,00c '.}' 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 the Ryles and Regulations of"the San Joaquin .'Local Wealth District. .f '4 iY ., 3+�, ;.s - -e F f/J � Jab Address / / 0A t.'City' y Lot Size PM T. .,r t 71r.-LL::" - -1,-W D)S 't:.✓ 'C',c.it� , Owner's Name VOA44,� �� n + Address ad Phoney 4 0 Contractor oke � _-Add res s License No! Phone 4164"�C `"TYPE OF WELL/PUMP: NEW WELL JW- WELL REPLACEMENT -' DESTRUCTION O PUMP INSTALLATION ❑ '�" SYSTEM REPAIR .EJ .OTHER"❑ ' -DISTANCE TO NEAREST: SEPTIC TANK .00A1 SEWER LINES I-�� DISPOSAL FLD. �� PROP..LINE Saar FOUNDATION � AGRICULTURE WELL "`� ` ,OTHER WELL'-� PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM-AREA--,CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑.,Open Bottom ❑ Manteca_ I Dia.'of Well Excavatio Dia. of Well Casing *'Domestic/Private li-Gravel Pack ❑ Tracy `'` Type of lasing - Specifications F EJ ❑Other ❑ Delta + ^ Depth of Grout Seal �a Type of Grout 9Q ❑ Irrigation pprox. Depth'} 7rEasterni i<r �� Surface•Aaf IMtalled by F Repair Work Done ❑ Type of Pump I�P. M State Work Do e "Well Destruction �` W1 II Diameter Material (top 501 Depth' d:rL?2 ;+Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ !DESTRUCTION ❑ ;(No septic system permitted if public sewer is-, :available within 200 feet.) �. k Installation will serve: Residence_ Commercial_ Other Number of living units: �' Number of bedrooms �~ Character of soil to a dept`-of 3 feet: Water table depth SEPTIC TANK ❑ Tyr:pe/Mfg Capacity No. Compartments Qk' PKG. TREATMENT PLT. ❑ Method of Disposal Oistance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines 1-`� Total length/size FILTER BED ❑,+'Distance to nearest: Well 'Foundation Property Line ;. a F4 SEEPAGE PITS " ❑ Depth - Size Number 1 J E 1 SUMPS ❑ Distance to nearest: Well Foundation 'Property.Line 'DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance wkh San Joaquin county ordinances, state laws, and €rules and regulations df.tK6 San Joaquin Local Health District. f,�' •� ° Home-owner,or licensed-ageni's signature-certifies the following:"'I°certify that'in the'performance'of-the"work"for which this permit is issued, I shall not ploy any person in such manner as to become subject to workman's compensation laws of California." Contractoes hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." ! i The applicaym must call for all required ins. ' ns. Complete drawing on reverse side. Signed X Title: Date: _ 4 + FOR DEPARTMENT USE ONLY Apptication Accepted by Y Date S- ' ��" Area dq Pit or Grout Inspection by Date 's/'yam Final Inspection by Date t Additional Comments: r E,- Stk 466-6781 E3 Lodi 369-3621 ❑ Manteca -7104 El Tracy 835-6385 �� IAI t,,,�A plicant- Return all co ies to: nvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box Stk., CA 95201 P1 Fie sd +. 3 .. r. - wl F FEF �... INFO AMOUN9►T DUE AMOUNT REMITTED CASH RECEIVED BY DATE. PElRMIT NO.' b +EH.13-24(W.F/asl EH 14-28