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ti rA`•.tit APPLICATIOWFOR;PERMIY SAN JOAO.UIN,,.LQCAL MEA_LTH DISTRICT 'r 1601 E. ,HAZELTON.AVE., STOCKTON, CA Telephone (209),41W6781 r,t.• j n: )�i l 4 PERMIT EXPIRES YEAR,FROM,DATE i$S�JED � �rF u;.�y', :t .f t if.isee�^: {(:O[11f]IEte lll�TClfJlica�el,.�3,._.. C e=ilwis'z:;7{ {t:..r.','3tReifL 4 !\t';��j'�t:ilT "r•,•., i_ i1r•�\r'v Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein idass application is made.'in;corhpliance withsSan Joaqu!n,CountyOrdinance,Na:549,for sewage•or No 21862 for well/ophip and the Rulesond J ulat s'`of the San,Joaquin Local Health Districtr 6, :_ .. ,.c'$,. .s . .'rti., � j ,+ i 3 Styx •� t ,:aF DC7 €t, �.' s _i' r.'i'tfd.y Job Address t=F r !tY r 7�!? ©/dot Siza. _ PM. _ Owner's Name Address PFione _-Contractor's_Name 7r� License No Pl one 66,62 I � - TYPE OF WELL/PUMP: 1 NEW WELILL ❑ WELL REPLACEMENT C] DESTRUCTION ❑. I '"PUMP-INSTALLATION' SYSTEM,REPAIR 0 OTHER El;' r DISTANCE TO:NEAREST: SEPTIC-TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELLSOTHER WELL. PITS/SUMPS INTENDED USE TYPE OF WELL: PROBLEM AREA CONSTRUCTION SPECIFICATIONS :❑ Industrial r- - - ❑ gpen-Bottom ...CI-Manteca Dia. of Well Excavation - Dia. of Well Casing VDomestic/Private ❑Gravel Pack 0 Tracy Type:of Casing Specifications ; ❑ Public . ❑ Other ❑ Delta Depth of Grout Seal ` Type of Grout f• (].prrigation.... .......... ._. --pprox.PDepL s �Surface Seal Installed by. } Depth ❑ Eastern I Repair Work Done : ElT e of Pum H P ' State Work Done/Wr ` R ti ap- r Well;Destruction ❑ Well 6iameterSeali - ng Material {top 50'► Depth f Filler� _. _. Material {Belovi`r 601 ,TYPE OF SEPTIC WORK: NEW INSTALLATION 1:7 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is »_. r_ available within 200 feet.) i Installation will serve: r'Residence_ Commercial Other Number,of living units:' Number of,bedrooms -- -Cher of soil to a de th,af 3 feet: s.-. _ ;_. t_. Water table depth aract P NK ;❑ Type/Mfg Capacity No. Compartments SEPTIC TA Q , jPKG.,TREATMENT PLT. ❑ Distance t Method of Disposal _ . o nearest:: Welt ;' Foundation ? Property Line LEACHING Ll E _ ❑ No & Length of lines , T ` .. g � Ilength/size , "FILTER BED ❑ Distance to nearest:; Well �----Founda ., ... ._ �:_.._� :. __.Property tine- tion SEEPAGE PITS Cl Depth Size Number "'SUMPS -,Q '•Distance to nearest:; Well Foundation _ •Prop erty-Line 4- -r DISPOSAL PONDS: �❑ I hereby certify'that l have prepared this application and that the work;witl be done iwaccordance with San Joaquin county ordinances, state'laws; and rules.and Fegulations of the San Joaquin Local Health District: Home owner or licensed agent's signature certifies the following: I certify that in;the performance of the work for which this permit is issued, shall not 1empl6y arty-person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or;sub-contracting sigriature certifies the following: I certify that in the performance of the work a ; ` g•" k for whicK this permit is issued I sh'il employ persons subject;to workman's compensa-tion laws of California." .- The applicant call for al Lre uired insPActions' Complete drawing on reverse side. ; Signed X t L Title Y eR{ Date T`U _ I i R DEP MEN SE:ONLY `/ , Application Accepted by: I Date Are ! ' � A Pe y ; Date�� Prt or Grout In§ ctian b y 'Date Final In ctian b +Additional ;Commentsf/ _ — { ' ' haemi❑ S k -466- l _ ❑ odiM-3621 362 ❑ E iazalton Applicant, t all co : Ennmental Health 1601P.O.O Box �5tk CA 95201` ry I 1 i CASH _ . . ..,_ m.. FEE ` """':AMOUNT bUE 'l"' AhlIOUNT REMITTEb ' CK ;RECEIVEb,9Y" DATE' j�EMlT''NO' a .!INFO. i } EH 13.24{REV.10. l83i '