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1PLICATION FOR PERMIT SAN JCrAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) descgibed This application is lienee with e t +he S,n County Ordina ce No.549 for sewage or No. 1662 for well/pump and the Rules and Reg°let'ons of the San Joaquin Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or atsiall the work here)^ made in comp Y'17 ,r/ �G�y/ Local Health District. / � "'"'""" W � Lot Size�-- PM � City wap Job Address � �r� P � J ��. 19 Phone P� M 0. 6rAddress Owners Name V V r at�5ry _Phone b License No.--r-.`^ ��w�( A br; 1 Address DESTRUCTION ❑ MOIU Contractor pJz.i.�- NE yyELL WELL REPLACEMENT ❑ OTHER ❑ TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ PROP. LINE —� PUMP INSTALLATION ❑ SEWER LINES DISPOSAL FLD. PROP. LINE OTHER WELL UMPS DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL FOUNDATION --/,�[/-- PROBL�AR�` CONSTRUCTION SPECIFICA IONS Dia. of Well Casing INTENDED TYPE ❑ Manteca Dia. of Well Excavation L $pecif'nations ❑ Open Bottom Type of Casing ❑ Industrial ❑ Tracy �A [, Type of Grout Domesti Gravel Pack Depth of Grout Seal ❑ Other ❑ Delta ❑ Public _�pprox. Depth ❑ Eastern Surface Seal Installed by ❑ Irrigation tate Work Done K; H.P. B cW Repair Work Done ❑ Type of Pump g_- Sealing Material (top 50'1 ECYV Well Diameter _ ell Destru tin Filler Material (Below 50'1 _ .i �1 Depth_`3 O— �'--- available within 200 feet.) AOM�OY" _— 0('1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ lNo septic system permitted if public sewer � Commercial_ Other_� Installation will serve: Residence_ Number of bedrooms Water table depth Number of living units: — No. Compartments Character of soil to a depth of 3 feet: r[y� SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG.TREATMENT PLT. ❑ Distance to nearest: Foundation Property Line l Total length/size ❑ No. & of lines property Line LEACHING LINE - Well Foundation - FILTER BED ❑ tance to nearest: Number ❑ Depth —Size property Line SEEPAGE PI Well Foundation SUMP ❑ Distance to nearest: tate Wws, and ,S POSAL PONDS ❑ I shall not I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin cch this p mance , rules and regulations of the San Joaquin Local Health District. rsons subject to workman's compensa- erson in such manner as to become subject to workman's compensation Wvrs of California.— Contractor's hiring or sub-contracting signature Home owner or licensed agent's signature certifies the following: "I certify that in ionthe laws Of Calrmit is 01 shall employ a�ws hi this permit o Issue employ any f 'I certify that in the performance of the work for which this Pe certifies the following:' tion laws of California." y The applicant st call for all require coons. Complete drawing on reverse side. Date: Title: SignedFOR DEPA ^8 RTMENT USE ONLY -- l � �--r Date Area %y Application Accepted by Date // k e) Pit or Grout Inspection by Final Inspection by Dat Additional Comments: ❑ Manteca 623-7104 ❑ Tracy 635fi"i65 tk., C 1 /S•f-' / ❑ Stk 466-6781 ❑ Lodi 369-3621 Appli nt- Return all copies Sp. E^vtr°nme I Health. Per^'It/S�rv'ce�11 .1 E. Hazelton Box 2009 . .7S -, � �+sv.-�"' DATE PERMIT NO. CK# RECEIVED BY FEE AMOUNT DUE AMOUNT REMITTED CASH INFO 7� 1\ Jifr �7�0 S EH 13-24 tREV.Its 5) —`-� � EH 1425