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APPLICATION FOR PERMIT :- :SAN JOAQUIN LOCAL HEALTH DISTRICT- - � .,, 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 f j PERMIT EXPIRES 1 YEAR FROM DATE ISSUED x - (Complete in Triplicate) 2-u l i 1V Application is he eby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This applications he Rules and Regulations of the San made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for weii/pump and tJoagwn Local Health District. �t y�R F-LTA Z000 f �l'RF.fi e-C ,L zD A 4 rjCHuLT EZ1 p Ott R- TA cm,4f4l.0�j NE, Job Address ��u�'H^�� t F� 1ur= CE City Lot Size t 170 Acar. PM }lain RD ta►v,1 C�tar:<T �R�Ct. Address "�� tCLANih- Phone �ti .— Owner s Name m Contractor O� t Address R License No _1 Phone-A '' N 246 al 41 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ ` SYSTEM REPAIR ❑ OTHER )(Q9 pTe_CR9%CAL DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL - PiTS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom G Manteca Dia. of P3 Im Dia. of Well Casing Type y C. Domestic/Private 0Gravel Pack ❑ Tracy T YP of Casing Specifications 9 r � � i Public ' r l Other F Delta Depth of -a 16 1S ---k-N Type of Grout I i IrrigationApprox. Depth I I Eastern Surface Seal Installed by !� I Repair Work Done 0 Type of Pump x H.P. State Work Done Well Destruetion C1 Well Diameter-` Sealing Material Itop 50'1 lb Depth 1 Filler Material IBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) installation will serve: Residence Commercial _ Other �. 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 n F PKG. TREATMENT PLT. ❑ Method of Disposal f Distance to nearest: Well Foundation Property Line i t LEACHING LINE ❑ No, & Length of lines Total length/size rif FILTER BED ❑ Distance to nearest: Weil Foundation Property Line SEEPAGE PITS l I Depth { Size _ Number �" J SUMPS LI Distance to nearest: Weil Foundation Property Line 3 DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I I rules and regulations of the San Joaquin Local Health Di%trict- Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's 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." L The applicant must call for all t ui ed inspections. Complete drawing on reverse side. Signed Title: G Date: �.,P gII-L "Pt F R DEPARTMENT USE ONLY ate 3 , + ` D ✓ _� Area I Application Accepted by _ Pit or Grout Inspection by Date_ LL Final Inspection by i Date 1f Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-362'1 ❑ Manta 823-7104 ❑ Tracy 835-6385 c Applicant - Return all copies to: Environental Health Pefmit/Services 1501 E. Hazelton Ave., P.O. Box 2009, 5tk., CA 45291 FEEAMOUNT DUE AMOUNT REMITTED CASH i RECEIVED BY DATE PERMIT'NO. INFO . EH 13-24(REV,118 5) Ell 14.26