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1• APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.,HAZE.',T ON}AVE., STOCKTON, CA % _.i.. z iso r Telephone (2091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin 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 �J�L+o �_ (,J. I v/ I! L/ RU.- Cit H•C/ot Size PMCA ! owner's Name __ � .. a d2"f� dress /` d Bix 6A�.,, - �K hone OT--46 711 1 „ ntracfo� _ 4ddrets �,� :i License'.No PJf v�+�" I -----"TYPE OF WELL/PUMP: - r- _ EWWELI _y ,-WELL REPLACEMENT_. r DESTRUCT-10 PUMP INSTALLATION I� SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES /da DISPOSAL FLD. PROP. LINED FOUNDATIONSDI AGRICULTURE WELL 3�0 BOTHER WELL_-.._ _ PITS/SUMPS ",0 a INTENDED USE TYPE OF-WELL.t, 1 PROBLEM AREA CONSTRUCTION SPECIFICATIONS 17Industrial ❑ Open Bottom ' I {p Manteca'- Dia. of Well Excavation Dia. of Well Casing �.�C 4 f I .1111mestic/Private Id�t;ravel Pack h Trky .i a1 ` mType of'Gasin9 Specifications t� } r Public ❑ Other l Delta Depth of Grout Seal 7ype of rout I I IrrigationApprox. Depth i.l Eastern Surface Seal Installed by 4• Repair Work Done & Type of Pump <rfzb H.P. � � State Wor Done Well Destruction AR"'Well Diameter +f 5jaling Material flop 501 Depth �°' l!IhL /anFiller Material (Below 50, +l TYPE OF SEPTIC WORK: NEW INSTALLATION (.I REPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence' Commercial Other Number of living units: Number of bedroomsxy I Character of soil to a depth of 3 fee{: x J+ Water table depth s t SEPTIC TANK ❑ Type/Mfg _ Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method,of Disposal i Distance to nearest: _W011- Foundation fPropehi Liner" -"�-- i 1 LEACHING LINE ❑ No. & Length of lines Total length/size y 1 i 4 FILTER BED ❑ Distance to*nearest: Well! Foundation Property Line ' SEEPAGE PITS ['I Depth_r'' g- <` t Size -Number.- SUMPS Ll Number --SUMPSl Di§tahce to,nearest; Well Foundation,-'+ Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and tfiAtithe`hiark willtie done in accordance with San Joaquin county ordinances, state laws, and s,.k i f rules and regulations of,the San Joaquin Local Health District. Home owneies the following: "I certify that in the performance of the work for whish this permit is issued, I shall not employ any p on in such.man ryas to become subject to an's compensation laws of California." Contractor's hiring or sub-contracting signature j certifies the Ilowing: "I certify t m the perfor t e rk f R is permit is issued, I shall employ persons subject to workman's compensa- tion laws of 4 f The applica(California.-t must cat o equire r nspe ate dr ing on { Date: Signed X ills: F TM ENT USE ONLY Application Accepted by Wl9.a�• Data_ `2-�_S=� Area Pit or Grout Inspection by4) f D• .. �� Final Inspection by Date Additional Comments: 0 U-S r nvl ❑ Stk 466-6781 ❑ Lodi .369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copiesA : Env onmetal Y^h ParmiVService I, E. ton.0. P.O. Box 2009, Stk., CA 95201 FEE (NFA Ai MOUNT DUE AMOUNT REMITTED CK 49 CASH RECEIVED BY DATE PERMIT'NO. +.EH1 -24[REV.A n sl tp fy } EH 144-29 � � "'�