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;. � APPLICATION FOR PERMIT ( SAN JOAQUIN LOCAL HEALTH DISTRICT Not 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (.209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heteby made to the San Joaquin Local Health District #or a Permit to construct and/or install the work herein desaibed. This application is made in compliance with San Joaquin County Ordinance No. 549 #or sewage or No, 1862 for weillptimp and the Rides and Regulations of the San Joaquin Local Health District. Job Aorliess City 7 rtJ Lot Size d c PM Owfter's Name _L, .ti� _1 _ �Pdt fit._ Address Sof t Phone Contractor �Lrr y✓ia Cllr I.>_.__ Address-_7,ALr_GLb�" -ti Qy-• License No., TYPE Of WELL/PUMP: NEW WELL Ci WELL REPLACEMENT Lj DESTRUCTION U PUMP INSTALLATION C SYSTEM REPAIR 0 OTHER C! DISTANCE TO NEAREST: SEPTIC TANK_SEWER LINES /DISPOSAL FLO._ _— PROP. LINE .. FOUNDATION _ AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE '71 Industrial _ 0 Domestiel Private I") Public I I Ink yiitiron Repair Llrnrk Clone L Weil Destruction -7) TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L Open r3ortzsm C7 Mar+teCa Dia, of Weil Excavation U Gravel Pack i i Tracy Type of Casing..____ 1;:l Other _ r Delta Depth of Grout Seal _ --Approx. Depth —Y i I Eastern Surface Seal Installed by ~ Tyrie Of Pump(,,, �_ State Work Done Well Diameter rl Sealing Material Itop 50') " Depth $ '" fiber Material t8elow 5W) Dia, of Well Casing Specifications Type of Granit TYPE. OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION DESTRUCTION i I fNo septic system pemtitted if publ;c sewat is Installation wiH serve: Residence �__...:�;Commercial _...,_` Ott}er avabable within 200 feet.) _....�.._____ Number of living units: L_ Number f bedrooms _ 10,_ Chatactar of Boit to a dep!p of 3 feet: _ ir• d. zA y _.. . Water table depth SEPTIC TANK Type/Mf4. ---- r gil, Capacity-0--ilit-a— No. Compartments _- PKG. TREATMENT PLT. [ Method o! D` isposal Distance to!neare'st: Wall Pouridation _. �� Proprtty Line LEACHING LINE No. ,& Length of litres , Total lengthlsire FILTER BED CI Distance to neaarrett: Well ' _ — Foundation., Property Line.. r SEEPAGE PITS Depth Sire Number SUMPS Distance, to nearest: well, rSd rFoundation _,1 d I. Property Line _ DISPOSAL PONDS '`� I hereby certify :ihat I heve_pteparec9 ibis application and that thil tirk,w+itl be tfona. in accoldorite with San Jaaeluin county rules and regulations of the San Joaquin Local N4alth District i my ordki noes, state laws, and _Name owner ar licensed agent's signature certifiesthe fioibwitigt,"I certify thea rirtfia Performance of the work for,which this j empiny any person m such trtarenbr as to fsecome sub` fermi is issued; I. shall nal certifies the fottvw�n t "to-warkinan's carnpansetion laws of`Ceiifomia." Contractor's hiring or sub -contracting signatuie g: ' -"C6rtdy diet ran the Performance of the work for which this p i mit ire irsuad, 3 aty err,ptoy Persoms subiact to :workman's cairsjaensa i tsan taws of California.' 't, ' - The applicant must call four all rreryluited in i ioftB. Complete -drawing -on rovertie'side, t � SignedTidw F014 PEP'ARTMENT USE ONLY �j APpl+cairon .Ac7c trk1 Pit or Grout Inspection by para final itr {� _gyjO spection by Dated �' Additional Comments: " - / 49 4* fA Sik 45667$1 0 Lodi 369.3621 0 Manteca 823.7104 Ll Tracy 635.5 4Ppiicam " Return all Copies to; Environmental Health Pema'rtlServ'icas 1601 E, Hazeltrzn Ave., P.O. Seta( 200% Silk., CA 95201 I EE6 AMOUNT AMOtlNT R£MITi Ell _ --� �- •�- „« i IN CK RtC£tV£h 8Y HATE ��F£AMI?`AID. . EH 133 ittfV.>> A s;L--J-- 1 —77, IT—,itl A