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APPLICATION FOR PERMIT SAN,JOAO,UIN LOCAL HEALTH DISTRICT 1601 E;CWJEL l ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED. (Complete in _T_riplicate) � a�� r; kation-Is gppfieation is hereby made to the San=Joaquin Local Health District 549 (sewage or No. 1862 for well/pump and theRulesand IRegu ations of the Sa Joaquin made in compliance with San Joaquin County Ordinance _ Local Health District. . } F' „ry City iv�ot LZI d 1 Ili40 � job Address -��s•, ,LGp�yj �DNS� fy� Q ,4t1ar ss fP Phone L Owner's Name 't �� Phone r _Address 11, �!� License No. contractdr DESTRUCTION:❑ +TYPE OF WELL/,PUMP: NEW WELL WELL REPLACEMENT ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHE�R��' i-' k �. '✓ PROP.ELINE �y " i �"E� `ZCV'r SEWER LINES �- DISPOSAL FLD. -DISTANCE TO,NEAREST: SEPTIC TANK —��- OTHER WELL ° PITS/SUMPS y' FOUNDATION,:�-- AGRICULTURE WELL ,� ) gee J0 WELL f TYPE OF PROBLEM AREA CONSTRUCTION SPECIFICATI NS i/ _ 1NTEf DED USE 7/, Dia. of Well Casing ❑ Open Bottom ❑ Manteca Dia. of WelllExcnvation� ndustr"ial: l,. Specifications Type of_Casmg C] Domestic/Private 'N 0 Gravel Pack EI 4�;, '� Type of Grout�4 r� ,5 ❑ Other ❑ Delta Depth of Grout Seal ❑ Public / i� ' 1 -� �4pprox. Depth ❑ Eastern Surface Seal Installed by I 1 v G tj 0 Irrigation ` j� _ State Work Done' s i Repair Work Done/� Type of Pump �`�� H.P. i; / Sealing Material (top 50'1 Well Destruction ❑ Well Diameter" �-- - --�- �----^'-''I Depth Filler Material (Below 50'1 # TYPE OF SEPTIC WORK:ANEW,INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ aNailablelwithine200 feet.) if public sewer is \, { `t: - i r; 1 Installation will serve: �fl- iidence�' Commercial Other `' 1 + _� , Number of bedrooms . k-Number of living units: Water table depth ; f ' k Character.of soil to a depth of 3 feet: No. Compartments •�` I ❑ Type/Mfg Y^' Capacity i SEPTIC TANK--: +�� Method of Disposal ' PKG. TREATMENT PLT.`•❑a ',- ( j k v Well Foundation Property Line Diance,to!nearest• zc"t Total length/size LEACHING LINE ❑ No. & Length of'linnes Property Lime ' Foundation I "FILTER BED("-J � ❑ D'+stance to nearest: s` Well , 1Size Number SEEPAGE PITS K ❑ Depth Foundation Property Line ❑k Distancetoneatest: Weil ,. (;.', , t SUMPS • � } k"i� 'A DISPOSAL PONDS ��'i '� `� i hcation and that the work will be done in accordance with SaniJoaquin county orifinances, state laws, and Thereby certify thaII have prepared-this app' I -- rules and regulations,of the San Joaquin Local Heath District. Home owner or;licensed agent's signature certifies ilia following: "l certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."employ peo�nsjs bj ct t workmang or 'scompensa- certifies the foNowing:"I certify that in the performance of the work for which this permit is issued,I shall employ p 4k - tion laws of California." The applicant m5zgz5i��drawing on r rse de. Date:X -�+ � c TitleSgned , ' e t FOR DEPARTMENT USE ONLY ; Date 13 - ` Area Application Accepted by I ZT- � Final In by Date l ` Inspection M Date r ( t_f Pit or Grout pe -ilia/ - —Additional-Comments: - l _❑ Manteca 8?3 7104 ❑l Tracy 835`x5 - ❑ Stk 466-6781 ❑ Lodi 369-3621 Stk., CA 95201 ='Applicant=-�Raturri-all copies-to:-Environmental'Health Permit/Services 1601"E-Hazelt6n Ave.;P.Q. Box 2009, i CK DATE PERMIT NO. z, FEE CASH RECEIVED BY INFO AMOUNT DUE AMOUNT REMITTED + EN 3-24(REV.)/e 5) EH 14-28 ��`