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r �- APPLICATION FOR PERMIT �..._.... dL�HEALTH DISTRICT SAN JOAQUI� ED 1601 E., WA ELTON AVE., STOCKTON CA Telephone 12031-466.6'181 PERMIT EXPIRES VYEAR FROM`DATE ISSUED' le fC (Complete inTriplicate)f R. , .. N 1.. .... C 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. 1662 for mill pump and the Ryles and,Regrulaticum of the San Joaquin Local Health District. - '' .,,... ,t. a ,,..:; ./ -, e. r.r • .», ': �cJ 1 C LotSimPM Job Address tiv. �Mi/�:/' •.. I_ _ . Owner's Name A/en 1!i.i�[ .g�rc� -�Address C�tiL� ��.:. .�L'�r�ih .��-7.,.:� .Phone G -�j ,c, f Contractor'Q�Lj f 't- k 1�) 6 Address t License No.=95 L-Phone/^4/1' 0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL RE CEMENT 11DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR O OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE — FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ndustrial [10 n Bottom ❑ Manteca Dia. of Well Excavation Die. of Well Casing ' ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications q❑O Public ❑ Othy ❑ Delta 1/'Depth of Grout Seal Type of Grout 1 -Repel Irrigation -�pprox. Depth ❑ Eastern �-// S`u'rface Seal Installed by Repair:Wbrk Dane ❑ Type of Pump H.P, p' '`,. State Work Done IWell OestNia'gn ❑ 'Wall Diameter 3-- -^^-Sealing'Matariah(top50'1-- - _I +--Dopy+ .SC7a Filler Material (Below 5011 ,TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted H public.sewer is r� /tr\ /�'7�l available within 200 feet.) j ,Installation will serve: Residence_jl'oftlmwcisl_ Other Ilt Numberof living units: _ Numba/r of badroorrs l Character ot.soil to a depth of 3y,,/feafg �' ' / �� Water table depth t SEPTIC TANK 1 ❑ Type/Mfg .' `-�` t �♦ Capacity No. Compartments PKG.TREATMENT PLT. 1111J` Method of Disposal i.. , Ionce to earest: Well l ' Foundetit� ��/ Property Lina jr ; '\ n � ( ' ^ Total len /size I t LEACHING'LINE s O No.6 Length of linea V 9th I � ' FILTER BED ` �iatanc i-to-nearest: Well Foundation Property"L� SEEPAGE PITS ' , ❑Depth. ��'l^ Sita- Number ; SUMPS � ❑i'bisFance to nearest: Well - Foundation _ _Propeny Urte'�. MIRPOSALtPONDS ♦❑ ' I hereby certify that i have prepared this application and that the work will be done in accordance with San Joaquin courtly ordinances,state laws,and rules and-regulations of.the San Joaquin Local Health District. f'/ r .' -I. Home owner or litCansed agent's signature certifies the following: "I certify that in the performance, Bf the work for wh- ich this permit Is•issued,I shall not employ any poison iry such manner as to become subject to workman's eorApensation 16ws'of Califcmja"'Contractors hiring or sub-m- signature 0ea carti �.the foaowirg: "I certify that in the performance of the work for which this permit Is issued,Isfiell employ persons subject to workman's compertsa- tion laws of Celyarnia." The applicant m uire inspections. Complete d Signed rawing-o verse sinde.— , - 1 Data: Tiye:r._ . i FOR DEPARTMENT USE ONLY ' Date � � . Arae J Application Accepted by + Y t Pit or Grout Inspection by Data Final Inspection b Date s 1' 'Additional Comments: ❑ Stk 486-W61 ❑ Lodi 369-3621 ❑ Monte= 823-7104 L3Tracy 636-6386 ^ Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,CA,S5l01' IFEE AMOUNT DUE AMOUNT REMITTED CK s RECEIVE' By DATE PERMIT'NO. _J3 y ys Cr i