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�---� APPLICATION FOR PERMIT ON JOAQUIN LOCAL HEALTH DISTRO 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) /or in all the work n described. This cation is madle nncomplliance with San Joaqu nnCouJoanty Ord nauin Localnce Nto.549 for sewage or Healh District for a permit 1862 for cweii/dpump and the Rules and IR Regulations of he San'Joaquin Local Health District. (1 O 1.1 �� ,C_� _,O^, inn T ^n PM City __ . -__. Lot Size Job Address _ 3�Inq_a 9_2C°'7 L. -'n i�r27 C -Roth f Phone _�, : :c. _ i Owner's Name Address Mob,lc(9fb ✓rte- 4l` Address ; License No. ;7 Phone _ Contractor " - --f-" -- TYPE OF WELL/PUMP:( NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ -- --- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ;t Dia. of Well Excavation ' _ Dia. of Well Casing C1 Industrial ❑ Open Bottom :0 Manteca -' Type of Casing Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy YP 9 �- ?- -- Depth of Grout Seal - "--�' Type of Grout F1 Public 171 Other Cl Delta I I Irrigation J3.__.Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H P State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') - '�'" Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (Nailabetic system rented if public sewer is Installation will serve: Residence_ Commercial_ Other Number of living units: — Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT. O Distance to nearest: Well Foundation Property Line E>• T LEACHING LINE ❑ No. & Length of lines Total length/size [C p .� + R�\ FILTER BED ❑ Distance to nearest: Well Foundation Property Lin`�.p_L�-1992 SEEPAGE PITS I I Depth Size Number RI IRI .r HEN T14^-- MJICES SUMPS ❑ Distance to nearest: Well Foundation Pr0{1`J18,RONMFNTAI HFAi TH DIVISION 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 rules and regulations of the San Joaquin Local Health D13trict. 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." Contractors hiring or subcontracting 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." The applicant must call for all required i spec tio!n's. Complete drawing on reverse side. Signed X _ JG- Title: D ~'`'`' Date: pPj i� 3rr`I�Y�^ LI n rp ` DEPARTMENT USE ONLY 3 Q '/2 b Application rAcceptetl 6y ` Date Area ryp)y7SaVa4Pa ' tn2— Date 3 aFO Pit or Grout Inspection by Date -( Final Inspection by mom/+ /+ Pfe PSG >°� Pao P9 Pq6 Additional Comments. � / -� -J--� f ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 83563M Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMyOUNT REMITTED /CASH RECEIV,ED�J9Y DATF�2— PERMIT'NO. 51 INFO O O— sq O 11}t4IREV.iix � 147a