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f } � APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ;PERMIT EXPIRES TYEAR FROM DATE ISSUED r (Complete in Triplicate) 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 Sa�JoaquinCou',n dinance o.549 for sewa9lBor No.GG�1(362 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. F�b9 Job Address C> l 4 ` ` City i6<:; � ti Lot Size a� PM -- t CON CG�Q�i Phone Owner's Name &eR/tJ�/i Address- r,� t Contractor /-&000� :Address fGf /Y9 m/a License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION' ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION`' - 4 RICULTI qF WELL OTHER WELL '' PITS/STUMPS INTENDED USE TYPE OF WELL _. PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of ell Casing ❑ Industrial J ❑ Open;dottom ❑ Manteca Dia. of Well Excavation I Type of Casing SpeciTications ❑ Domestic/Private ❑'Gravel Pack ❑ Tracy YP g z Depth of Grout Seal Type of Grout s I`I Public F3 Other fl Delta I I Irrigation .. Approxi Depth l I Eastern Surface Seal Installed by H.P. State Work Done Repair Work Done ❑ -Type of Pump Well Destruction ❑ Well Diameter Sealing Material Stop 501 l� t Depth I Filler Material iBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTIONI-l (Noa4a.septic systemithin feet�tddit pu'b4 sewer is Commercial— Other Installation will serve: Residence+ i c i t; ` a`, Number of living units: Number of bedrooms• Character of soil to a depth of 3 feet: r Water tabl ,depth /� I Capacity_a u-p No. Compartments ' ' SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ 'J - idation-Z Property Line�/�7 Well to nearest: L r ,r :� ' t: Total length/size r„r,_ LEACHING LINE ❑ No. & Length of lines Property Line_ .1 Foundation__1 P rtY FILTER BED � ❑ Distance,to nearest: Well —, - Number SEEPAGE PITS I I Depth .l Size Property Line 1 SUMPS LI Distance to nearest: Well Foundation 1 DISPOSAL PONDS ❑ I' 1 I hereby certify that I have prepared this application and that.the work will hb:done'in accordance with San Joaquin county ordinances, state Paws, ant rules and regulations of the San Joaquin Local-Health District.;, Home owner or licensed agent's signature certifies the•fallowing: "1 certify.that in; a performance of the work for which this permit is issued, 1 shall no employ any person in such manner as to become subject to workman's compensation laws of California." Contractoigub'ect to wng or corkmant's�cdmpetnsa certifies the following:'"1 certify tfi�t in-the perfokmance of-the work for which this permit�is;ssued,I shall employ pe 1 t, tion laws of California." ��^! The applicaa,must call for al eqi fired *specti s. Complete drawing on reverse - Date: Title: I d l Signed X1 � ~ FOR DEPARTMENT USE ONLY `1 1_L1 J92— Date ' Area Application Accepte&15v QQ�_.,,//Ol Date Final Inspection by Date Pit or Grout Inspection by t Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 D Tracy 835-638 •P.O. Stk., CA 95201.. : - Applicant- Return all copies to: Environmental Health Permit/Services 1601_E,-Hazelto!~,Ave„ P.O. Bbx.2009, .._' r r • PERMIT'NO. MOONTEMITTD - rCK BY DATE .FEE_ —AMOUNT DUE" CASH INFO . EH 13-24(REV.I/N5)