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IttI APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT a 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6761 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) n described.This t to /or in all the work _ madec nt1compl ante wication is itthade SanoJoaquin County Ordinalnce No. 549 r sewagHealth District for ae or INo. 1862 forcwell/dpump end the Rules and 1Regulatlons of he San'Joaquin Local Health District. rt�y y, �� d _ Cit .( Lot Size "'� PM Job Address /27 71 RJB / 12 Address I /l Phone Owner's Name r Zy z—?-G Phone�� �/� /l n�1(�1n7i''td-( License No� Address ` Contract WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPE OF� NEW WELL ❑ OTHER 11 SYSTEM REPAIR ❑ PROP. LINE PUMP INSTALLATION ❑ DISPOSAL FLD. SEWER LINES DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL PITS/SUMPS FOUNDATION INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Open Bottom ❑ Manteca Dia. of Well Excavat(on ❑ Industrial Specifications _ ❑ Tracy Type of Casing _ ❑ Domestic/Private ❑ Gravel Pack Depth of Grout Seal Type of Grout__ ❑ Other ❑ Delta - ("1 Public ,_ H.P. Surface Seal Installed by I I Irrigation Approx. Depth ( I Eastern State Work Done— Repair Work Done ❑ Type of Pump Sealing Material flop 50'1 Well Destruction ❑ Well DiameterEijjAr Material (Below 501 Depth------ p available within 200 feet r TYPE OF SEPTIC WOflK: NEW INSTALLATION I 1 REPAIR/ COITION DESTRUCTION I I INo septic system permitted if public sewer is r Commercial_. Other / S Installation will serve: Rest ante.— - Number of �1 C �� III- Character Water table depth umber of living units: Numb of soil to a depth of 3 feet: No. Compartments _ Capacity SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ Foundation Property Line Distance to nearest: Well / 1' / /Total length/size C y / LEACHING LINE No. & Length of lines I/ G-/�J r Foundation Zproperty Line�-- FILTER BED ❑ Distance to nearest: Well / Size Number SEEPAGE PITS - YT Depth �)Q` Foundation /n Property Line SUMPS ❑ Distance to nearest: Well 1� q y and DISPOSAL PONDS l Ll hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin count ordinances, state mit is issued, I shall not , 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 work for which this actor' h ringofto workman's compensa-- Home any person(n such manner as to become subject to workman's compensation laws of California.'" Contractor's hiring or subcontracting signature certifies the person follo (ng: "1 certify that in the performance of the work for which this permit is issued,1 shall employ pesubject tion laws of California.' The applicant( at call f�/(Iar�elilak�ed inspections. Complete drawing on rev�sp si�. Date: 'l _ \ re- „'t-'� —_— Title: I Signed FOR DEPARTMENT USE ONLY /�' Date Area � r � -- Application Accepted by O I Dat r �� Date Final Inspection by or Grout Inspection 6y Additional Comments: ❑ Tracy 835-6385 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Penn, 1601 E. Hazelton Ave., Applicant - Return all copies to: Environmental Health PerP.O. Box 2009, Stk., CA 95201 �91 RECEIVED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CASH �' _�53 _jq iq INFO ren �