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APOMATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-67$1 PERMIT EXPIRES 1:YEAR FROKA BATE ISSUED• i34Complote 1n Triplicate) Application is hereby made to the San Joaquin Local Health Di+strict for a permit to construct and/or install the work herein described. This apptication is made in compliance with San Jodquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, Job Address Q KM "'r w City I Lot`Size PM 33u1� 52 Owner's Name Icc%CA4 C�^�T ��Otl�cu s Address TO k,, S � Phone r i p � Contractor B ' F; �r�' 1f Address 36`6 3 0—di Cl" le,-#¢-License No. S�q y--Phone C1 i6�631 "�S b TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION ❑ {3 PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER Sc,i Bsr,+, C } i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL FLD. - PROP. LINE FOUNDATION. AGRICULTURE WELL t OTHER WELL PITS/SUMPS i . INTENDED U$E TYPE OF WELL PROBLEM Ali€A ` COI+1SfliUCTtON SPECIFICATIONS ` r rtrI ❑ Industrial EI Open Bottom ❑ Manteca r Dia: of Well Excavation Ax Dia. of Well Casing �} ^omesticl,l'rivate Li Gravel Pack / Cl Tracy � , Tye,of Casing No�4 Specific3iians i'f Public /Other &r°��f+3)F-! Delta Depth M Grout Seal 3f.t Type of Grout ! _ i I I Irrigation 3Q-Approk. Depth ! 1 1 Eastern Suilace Seal Installed by j Repair Work Done LJ Type of Pump rI H.P. State Work Done__ U► , Well Destrucilon I U Weil biameter �. Sealirig Mateiial 060 501 �t J ^►r k t I'�e.J r0•{ T -�' Depth 30_ }: - Filler Materiai;iBelow 50') r TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other. Number of living units: Number of bedrooins Character of soil to d depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartmenis PKG. TREATMENT PLT. ❑ Method of Disposal Distance to heare9t: Well Foundation Property Line 1 i LEACHING LINE ❑ No, & Length of lines Total length/siie FILTER BED ❑ Distance to nbaresti Weil Foundation - Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundatioh Property Line DISPOSAL PONDS ❑ 7 Aii ' 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 Di§trict. Home owner or licensed ag§nt's'signature certifies the following: "I tiertifyithat In the performance of the work for which this permit is issued, I shall not employ any person In such manner as to becomd subject to workmen's compensation laws of California." Contractors hiring or.sub-contracting signature certifies the follo jng: "I certify that in the performance of the work for which this permit is issued,I shall Employ persoris subject to workman'§compensa- tion laws of Cali 'r a.' The applicant d inspections. Complete Brewing orireverse side. Signe Title: �• r�C Date: 1 -6 FOR. DEpApTME10 Li$E-OhLY e�� C� t i eS Application Accepted by. ' 3` Dated (} �`� p breA r J,, J] Pit or Grout Inspection by ��l ate l Final Inspection byr't`.�/�1w . �"b t�Q Dale L 1 ' - - . ._ :x�� .... ,!. �.-"'.. '+fit.• <ro�• ,rw. Additional Comrnenis: ❑ Stk 4613-6781' ❑ Lodi 30-3621 U MahtecA 623-704 ❑ Tracy 835-6385 ° Applicant- Return all copies to: Environ"n'tol Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 IFEE NFO AMOUNT DUE AMOUNT fit PUTTED AS RECEIVED BY DATE PERM IV NO] +.EH 1 -24IREV.r/A5r EH 14-2E �i