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APPLICATION FOR PERMIT SAN JOAO.UIN LOCAL HEALTH DISTRICT ON AVE., STOCKTON, CA 1601 E. HAZE Y I6781 Telephone (2091--466- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (Complete in Triplicate) This application is um and the Rules an�egulauons of San Joaquin ' permit to construct andlor install the work harem described- Ordinance No.549 for sewage°r No.1862 for welllp p � Application is hereby made to the San Joaquin Local Health District for a pe made in compliance with San Joaquin County Local Health District. Lot Size 1), City L I _3 S 3� 5 Pi'one q 7 7 Job Address , 003 Address J l -' 3 ��Trona 7 I r 7 Owner's Name a �J \�A"4 LiCQnse.No.—�—� SSS~� ddress DESTRUCTION 13 ContractorNEW WELL ❑ WELt REPLACEMENT ❑ OTHER ❑ E SYSTEM REPAIR ❑ 1;00E TYPE OF WELLIPUMP: PUMP INSTALLATION ❑ DISPOSAL FLD. [ r SEWER LINES �� OTHER W PITSISUMPS 1 CIFiCATIONS DISTANCE TO NEAREST: SEPTIC TAN TIONAGRICULTURE WELL � FOUNDAS N TYPE OF WELL PROBL�'°`R�` CONSTRUC Dia. of Well Casing INTENDED USE ❑.Manteca . . Well Excavation specifications ❑ industrial Q Open Bottom Type Of Casing Type of Grout ❑ Gravel Pack 1 ❑ C] Domestic/Private ❑ Delta' Depth of Grout Seal ❑ Other Surface Seal Installed by ❑ Public �gpprox. Depth ❑Eastern Q irrigation State Work Done H.P. e ❑ Type of Pump � Material (top 50'! Repair Work Sealing uy estruction Q Well Diameter t`"'� ' Depth + Filler Material (Below 50`1 ' REPAIRIADDITION ❑ DESTRUCTION ❑ (No bperwithine200 feet.) if public sewer is TYPE OF SEPTIC WORK: NEW INSTALLATION _s ,;` —.- .':r Other Commercial, ' Installation will serve: Residence.— Water table depth Number`frooms Number of living units: � J t Q b No. Compartments Character of soil to a depth of 3 feet: it Capacity TypeIMfg Method of Disposal SEPTIC TANK # go f r �-u� Property Line---� PKG TREATMENT PLT. ❑ a Foundation�J Distance to nearest: Well Total length/size LEACHING LINE d No. & Length ofsines f�0 Foundation d Property Line ❑ Distance to nearest: Well_.�l F + I FILTER SED , Number ❑ Depth Size .�. ► Property Line 1� SEEPAGE PITS -r—Foundation SUMPS ❑ Distance to nearest' Well_�— . U # ❑ 1_„,.,�,e 4— ordinances, state laws,and DISPOSAL PONDS - t this application and that the work viriN.be done irr accordance with San Joaquin conn I shall not ::: I hereby certify that I have prepared ,� that in the performance of the work for which this permit is issued, nature rules and regulations of the San Joaquin Local Health District.` Home owner or licensed agent's signature certifies the following: "l certify arsons subject to workman's compensa- n person in such manner as to become subject otw°Nork for which this compensation its issued,I shall aemaploy peons hiring or sub contracting erg employ any following: I certify that in the performance of' certifies the following:" ;,,,�„�,s" `� � ,.,•�p.R< *�Z tion laws of Iif°rnia." tions. Complete drawing on reverse side. Date: i The applican u cal�for all re ired� s (f. il J` moi; �'Title: t i Signed ! FOR DEPARTMENT USE ONLY",-. s Date y—� a Area 7 J.rw►""`.' � Date Application Accepted by Final Inspection by 1 fL.�.� Dater� Pit or Grout Inspection by 5 n 5 S Additional Comments: vu;Manteca 823-7104 ,k . ❑Tracy ❑ Stk 46Crfi781 ❑ Lodi 369 Applicant- Return all copies to: Environmental:Health PermitlServa�s�1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520 DATE PERMIT'NO. OUNT REMITTED GASHRECEIVED J BY . .- AM + FEE AMOUNT DUE ✓J INFO +EH 13.24 IREV.t/a 5) �.EH14 ...