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APPLICATION FOR PERMIT SAN JOAQUIN',LO0AL�HEALTH DISTRICT r 1601 E.-HAZE'LTON,AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES,11 'YEAR FROM DATE ISSUED 1:7 1 t Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereiri described. This application is made-in coinpliance,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. A lvaq��ib jl ? -�-13173:7 �100�0; �W.W,�03 to sol-u0C, :)?Cj1uCQ Ix:jo t.qs 10 .,At:,V� .1VA1 .'b !,. - I .. - ' 't 10 VS"rq?1'fq z��41 f .)r1 9" ei niio Job Address •C tyLot Size,L t- PM 014249AA!4 Address Owner's'NameXV-7, 16-25 1 Phone M_ Contracto'lii!s.Na efw� License No. Cf t_.__-Phone TYPE OF WELLIPUMP: NEW WELL El WELL REPLACEMENT 0 DESTRUCTION,-El Jil PUMP INSTALLATION 11- 1 SYSTEM REPT 0 �, ._r OTHER- 1A PISTANCETO-NEAREST: SEPTIC TANKDISPOSAVFLDP R�c SEWER.LINES-A FOUNDATION �i 'A6RIq6l_TURE WELL, OTHER WELL E PITS/SUMPS :'_ tNT646E'Cf USE 14f TYPE OF WELL- PROBLEM SPECIFICATIONS CONSTRUCTION SPECIF C� -'E:l Industrial 'El'Maht4 Dia.'of Well Casing K, Open Bottom Dia. of Well Excavatio., 1-1 Domestic/Private El Gravel Padk E'Thduy Type of Casing_ Spgi�iftatiom -[3:Other D.Delta- Depth of Giout'r eal� pe' ' 4r- 4 4 Ij, I . --- - 11 Public S TV of Grout Depth- 6sfirn Surface Sial Installed by.' 10 1 rrigation,p%j -��(-j__._-AOpfox., I state 'Work Done 'Repair Work Done 0 Type 'of Pumpt H.P. 7 77 Wel(Mesiructibn F1 Well Diameter Sealing Material (top 50') + Depth Filler 4Material-(Below 501 -TYPE OF,SEPTIC WORK: NEW INSTALLATION�,4r-REPAIRIADDITION.EI DESTRUCTION (No septic system permitte&f,public sewer is I it le wobin 200 feet.,) .9s;weris k4 Comore Installation will serve! Residence_,�'C, 0 r 4 h r 4 Number of living units: N u mbar-of IfellMmm--r;k- I Character of soil-to a depth of 3 feet k - 3— Zv Ate" Water tabledp Ag- SEPTIC TANK Capacity No;.Compartments Type/Mfg. 4 � i PKG. TREATMENT:PLT0 I I Method of Disposal . y Ift T 'Distance to'nelarasst:�� Foundation k rProperty Line j 'LEACHING LINE 0jo`-&-L_ t engt4.o,f.Iine" 'FILTER BED- j _!rO 'Distance to-nearest- N Pr6p6o-Llne, 4 7. L I SEEPAGE PITS Depth Number �Ae SUMPS- I-]' Distance tS nearesf: )VyeIV QQC Foundation, _��:tUci arty Line DISPOSAL PONDS WIN I hereby certify that I hive pr6pared this applications and That--thMork will be done in'a'ccordance With Sin joaquir�"county ordinances, state laws, and 4 rules and regulation's of the San-Joaquin Local Health'District. - " — +j Home owner or licensed agent's signature certifies the foliowing: "I certify that in theoNrrormance of the work for which this permit is issued, I-shall not ..employ any person in such manner as to become sut48ct to-workman's compensation laws of California."Contractor's hifirig.br'silb-contracting signature certifies the following:"I.certirfy that in the-parf ormanA-of,the-1wvork-for-which-this:permit is issued,-I'shall-empioy-p6mons subject to workman's compensa- tion laws of C6Vornia." The appilca�nt n)us.t call,for requi Complete drawing on reverse side. _ r D)I S, A Signed k- Date: FOR DEPARTMENT,USE ONLY :Application Accepted by Date Area -4- C 07 i Pit Grout Inspection by Final Inspection by Date U, 4�. A �Acicli tional Comments: - C1 S�tk 466,6781 0 Lodi -389-3621 -0 Manteca-8237104-j- El jTracy -835-6385 Applicant- Return copies to: Environmental Health Permit/Services 1001 E. Hazelton Ave., P.O. Box mf 2�m Stk., CA 9520 INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`NO. 4 CASH F EH i34 -I.- —J !4 41111 V.1016 4 Em W26 A-