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I. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 'Telephone 1;.209) 466-6781 PER EXPIRES 9 YEAR FROM DATE ISSUED ;,• (Complete in Triplicate) r Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein deacril>ed. Tins application i< F made H compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquir Local Health District. :Iii' .• ., . :;, •.i,: r . Job Address5�% City Lot Size — PM _ t Owner's Name . Address ] _ f,+�� .Phone • Contractot.rl/>�OSCi� —Address `.�. `.fL✓}�_fo� ` �J TYPE OF WELL/PUMP: License Nor a7c� �v Phonek _6o S _ NEW WELL E3 ELL REPLACEMENT D DESTRUCTION ❑ f PUMP INSTALLATION U `'i� { 0 SYSTEM REPAIR [] % OTHER C7 f f DISTANCE TO NEARES_ IC TANK —. SEWER LINES _ FOUNDATI _DISPOSAL FLD. PROP. LINE ---- PROP. OTHER WELL, I PITS/SUMPS t' INTENDED USE TYPE OF WELL PRO—'— ' REA CONSTRUCTION SPECIFICATIONS U Industrial 67 ¢pen Bottom 1 Manteca.f ell Excavati- I r O Domestic/ private LJ Gravel Pack D Tracy Tyon W — Dia. of Well Casing of Casr g --""— C Public ❑ Other ❑Delta - —S pecifications Depth of Grout Seal _ _ L7 Irrigation — Type of Grout Approx. Depth n,Eastern Surface Seat Installed by_ — Repair Work pone 1 Type of Pump ._ H.P. -- — Well Destruction State Work Done ❑ Well Diameter Sealing State Ito 50'1 F i f44 p - t .• "' '"-.. --Depth — Filier Material (Eielow 5011 TYPE OF SEPTIC WORK: NQW INSTALLATION REPAIR/A.......... DESTRUCTION V (No septic System permitted if public sewer is Installationwill serve: Residence Commercial _ Other J.cO't g ilablo within 200 feet:] Number of living units: Number of §edrooms Character -- Character of soil toia depth of 3 -,feet: 2 SEPTIC TANK r r Water table depth -35 I� Type/Ntfgr _ CapacityQ� No. Compartments —a PKG. TREATMENT PLT, Fl� f Distance to nearest: I Well _ r Method of Disposal FoundatiunLine.' j / — _ Property Line .—, — LEACHING LINEo. & Len�th�of fi es v — FILTER BED t — — _Total length/size O Distance to nearest: Well Foundation _ „ Property Linc '• r G . -- —/ �-- — . _ SEEPA'GE'PIiS .- ffl''�dopth _ _Size . L�Q r SUMPS ( —1� -- Number _ �� I Cl Disiance to nearest: -# Well — Foundation _ — DISPOSAL PONDS - ❑ # — — Property Line --t - f ? I hereby ceitity that I have preParod this app?ication_and that the work will be done in accordance with San Joaquin counry`_ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed] ogenes.signature.certifies-1116-following: "I certify that in the performance of the work for which this permit is issued, I shall not employ AY po son ln;sueh manner as to become subject to workman's compensation laws of California." Contractor's hiring' -or sub -contracting signature tionl os•the Califon is certify that in the performance of the work far which this perrnit is issued, t shall employ persons subject to workman's componsa- tion laws of California." ? The applicant. ust call foFr�wired inspe tions. Eorfiplete drawing on reverse sid j SignedTitle:— Date: FOR DEPARTMENT USE ONLY Application Accepted by Dates b _Area;— Pit or Grout lnsp9ction!by-- ._ r G2%C — • Dato __ — Final Inspection by l .Additional Comments: °� � ' Date�` U-9ik" 46G -676t Cf Lodi "369-3621 - SVG Mantocti &23-7104 W Ci Tracy Applicant Rerurn all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT OUE AMOUNT REMiTTEOCK If — _• �� INFO CASH TRECEIVED BY DATE PERMli'NO (� EH 13.24 I kEv.irn E. UV t G EH 1129