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APPLICATION FOR PERMIT :I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephone (209) 466-6781 Q PERMIT EXPIRES 1•YEAR FROM DATE ISSUED i (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the rkwh rein described I This application i made H compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regul'i ' is i- Local Health District. 91�.6)ldA 5lnLJoaquin Job Address R E C li i City '"��'�tot Size �b. P a Owner's Name k Add ess 'hh j �KCE4T-L ' �1 �-7 1't5 t �qq ,p � I Contractor Address � 5q(4 -A/TYPE OF WELL/P Com' License N �htie . .IN EW WELL WELL REPLACE ENT ❑ DESTRUCTION ❑ - V - PUMP INSTALLATION ❑> - SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIChTANK :-L: SEWER LINES ~ DISPOSAL FLD!�,_3yd Zt� FOUNDh TION - 'A/ AGRICULTURE WELL OTHER WELL 200"' INE PPROP.ROP. LINE I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial O Open.�Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �Domestrc/Private ff-Gravel pack ❑ Trac C_ Y Type of Casing �M f'i Public �C7 ter' Specifications I I Irrigation Br ;40elta Depth of Grout Seal lv d0 Type of Grout .Ap.' X. Depth 1 I Eastern Surface Seal Installed by I� Repair Work Done ❑ Type of Pump H.P. .Well Destruction ❑ State Work Done li Well Diameter Sealing Material(top 5011 I� Depth Filler Material (Below 50') TYPE OF SEPTIC WDRK: NEW INSTALLATION t] REPAIR/ADDITID;' '111111111 11 N ! I DESTRUCT{ON 1 1 INo septics tem N�. Ys permitted i(public sewer is \ Installation will serve:. Rgavailable within 200 feel.i sidence Commercial Other _ I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANKWater table depth-. 1i I ❑ Type/Mfg PKG.TREATMENT PLT.❑ I Capacity - No. Compartments IM Distar�a to nearest: Well FoundationMethod of Disposal I$ � ' � LEACHING LINE 0 No. & Length of lines Property Line FILTER BEDTotal length/siz ❑ Die Ij stance to nearest: Well Foundation li l Property Line SEEPAGE PITS { 1 Depth I� Sue Number I� SUMPS 0 Distance to nearest: Well DISPOSAL PONDS Foundation Property Line ❑ 'i� li !hereby certify that I have !i 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'ktrict. I Home owner or licensed agent's signature certifies the followi i1. ng ��1 certify thatin the performance of the work for which this permit is issued I shall not employ Orly person in such manner as1to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following:"1 certify that in the Performance of the work for which this tion Iaws of California," i`s permit is issued,I shall employ persons subject to workrriaWs compensa- The applican t cal for all r quire Pd i pectiorls. Complete drawing on reverse side. Ij Signed - Title: 464� 1�V 1Date: F. DEPARTMENT USE ONLY Application Accepted by a I Date Area '�J�Z--• Pit or Grout Inspection by p �� FO Final_ Date Inspection by Date 2 p l.�s r / Additional Comments. •';�'Z� cT d H O Stk 466781 ❑ Lodi 369111`3621 ❑ Manteca 823-7104 ❑ Trac 835-&1 Applicant- Return all copies to: Envirgnmental Health Permit/Services 1601 E. Hazelt n Ave., P O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE INFO AMOUNT REMITTED CASH RECEIVED BY DATE F' ` PERMIT'NO: �H 13.24 TREY.t/n5f i� ta.za �' Uo .5ko ci i -