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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM•DATE ISSUED_- ii. �. (Complete in Triplicate) ` •'� "� ApDItation is hereby made to the San Joaquin Local Health District for a'perfnit to construct and/or Install the work herein described-This appilcatiori is -_made in compliance with San Joaquin County Ordinance No.54.9[ix sewage of No, 1982 for weillpvmp and the Rules and Regulations of the San Joaquin I oval Health District. p p /+ ` Job Address �� ff�/ Cb>-,Sf'of City /_.r11 G�— Lot Sae__��.�.._ PM .141 Owner Narne _ 'INO �7� �� Address ®oda 1.4- 3 f,FJ]'J� /]U. PhortA '��•S �'� d l Con!ractor ` � L/�� v�y A1d(e55.!P O'_Gl7lf E_�t ``� License fro. Y/, �!1 Phoneme- /'�/ f TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO,N I f PUMP INSTALLATION SYSTEM REPAIR n a`� OTHER'❑ DISTANCE.TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD- PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , C Industrial t _ Open Bottom C: Manttrw Dia- of Well Excavation r -___ Dia, of Well Casing L I Dome9t1CiPTIV3'V I Gravel Pack F1 Tracy Type of Casing ______..__.___—__ SpecfiGetiorta Public U Otter U De-ta Depth of Grout Seal _ Type of Grout ❑ Irrigation! —Approx. Depth C Eastern Surface Seal Installed by { _ Repair Work Done I Type of Purnp _ H.P_ -_-_ _. — State Work Done Wel Destruction ❑ Vftil Diamater _ Sealing Material Itop 501 _ -_____.- __ N Depth Fdlef Material 19elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION ❑ DESTRUCTION C (No septic system permitted if public sewer is available within 20D feet_I Installation will serge: Residence L Commercial_ Cther Number of living units=_/_ Number of bedrooms Y Character of soil to a depth of 3 feet: �M-wiJG �f/.��. N1'ater table depth SEPTIC TANK Type,Mfq _/��° CAST _. ___ Capaa`IY-baa— N Co ompartments PKG. TREATMENT PLT, ❑ Method of [hsposal Distance to nea(est: Weil ' fid + Foundationya+ _._ Prouetty Line A t LEACHING LINE No. A Length of lines �O I Total length?size ! r FILER 6E0 J Distance to nearest: Well Foundation Property Line SEEPAGE PITS :-i Depth. Ad SUMPS �1 Distance to nearest: Weft 0c' � Foundation'—�� "•Pr�rty Line jr DISPOSAL PONDS ❑ I r' 1 hereby cervfv that I have prepared this application and that the work will be done in accordance with San Joagu.ir county ordinarn:es, state laws,and A,, rules and eaulations of the San Joaquin Local Howth District- I - v •- i Home owner or licensed agent's signature certifies the foltovuing: 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner tri to become subject to workman's compensation Laws of California_"Contractor's hiring or sub-contracting signeturi— v - cartifins the following:"I certify that in the performance of the work for Witch this permit is issued,f shall employ per•wns subject to workman's compensa tion laws of California" I I c r I The applicant must 11 for all re uirec inspections, Complete drawing on reverse side. I?f r Signed K _ - _- . Title: Date: DEPAR ENT USE ONLY ti ; ( i 1) s Application Accepted by ! _ v ��`"t Dat -��L- � Arm Pit or Grout Inspection by %I Date _- — final inspection by_ r tiv+ J Date s Additional Comments:' ` C Stk 468-8781 ❑ Lodi 369-3621 ❑ Manteca 823:7101 1 ' Tracy 835-t i--- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hasetton Ave., P_O_ Box 2009, Stk., CA 95201 i I FEE tAMOVNIT DUE AMOUNT REMITTED RECEIVED BY DATE`' PIERMIT•NO. INFO CASH _ 10 zo-6 . EN 14-21i �' fff v r