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B R_ APPLICATION FOR PERMIT____ h SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE„ STOCKTON, CA 5 Telephone (209) 466.6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED rl " (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�` �'✓z N' "�,.{,. ""' ,/ City 1 fe^ � LQot Size PM Owner's Name yta,c3 U 1AA Address( 7 / ` ^''1_d//en awn �Cd',�-7�(��Phone t33` L�ET Contraci!0 C1 - �'+t WAddress . �':Z�7 .LZ�!License Noy —�Phone �a -S /O TYPE OF WELL/PUMP: ANEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑( ` f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. _ PROP. LINE ✓u FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , © Industrials ❑ Open Bo4tom 1 / ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ? 6 • Domestic/,Private s ❑ Gravel Pack Fj O Tracy Type of Casing . SpecificatIs , [1 Public '�'°Lh_'I OTh�� l n Delta f!, Depth of Grout Seal Type of Grout..: i I Irrigation 'LApprox, Depth ``I I Eastern '+Surface Seal Installed by - e. Repair Work Done 0 Type of Pump �s"'r^�' H.P. .,. �'I State Work Done _ Well Destruction 0.�WeII.Diam`etel',.-^^- Sealing Material(top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTAM'ATIQN I. REPAIR/AODITIONI I ' DESTRUCTION i l (No septic system permitted if public sewer is --*'-/ available within 200 feet.) Installation will serve: Residence— Commercial Other r7..Pq_.(1- L1 d_ Number of living units:`"dp�'Number of be cosrnCharacter of soil to a depth hbf 3'feet: Water table depth li SEPTIC TANK jt�' Type/Mfg bapacity /��9 67 No. Compartments PKG. TREATMENT PLT. 0Method of Dispo3at Distance to nearest: _Well•S4 Fouridauon_A2 Property Line LEACHING LINE ONo. & Length of lines Total length/size FILTER.BED ❑ Distance to nearest; ' Well Foundation 149 Property Line s.SD SEEPAGE PITS III Depth _�Z_2: Size © Number z SUMPS !8'-pistance to nearest: Well ! Foundation /h r Property Line DISPOSAL PONDS 4 fO I hereby cortify that I havd propare l 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 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, I shat(not i 'employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature'. certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa tion laws of California." Ii + The applicant n scall for all To uir ins ctions. Complete drawing on reverse �side. ---,t�� 44L, Signed X Title: ( ALL Date: .� --- --FORDE ARTMENT USE ONLY > ^- Applicat�onlAAcc�ceepteedd by Date Area ,Q!-? Z �it e�E%U't9n'spefeon by DateFinal on by GC�Gf7 Data .'Adtlitibnel'Cbmrtfents: ❑ Stk 466-6781 El Lodi 369-3621 ❑ Menteca��823-7164�e 1,A.O Tracy 836 6385 Applicant- Return all copies to: Environmental Health Perinli/Services 1601 E. Haielton Ave;F.*&Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY- DATE PERT79V INFO /� - TRE //aEH 12-M(R .1/ss) � lV I Cj /-" �('i 7�/�