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APPLICA ON FOR PERMIT ` SAN JOAQUIN LO HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED { (Complete in Triplicate) Application is hereby made to the San Joaquin Loral Health District for a Permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin Caunry Ordnance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin ! Local Health Distinct. �9b3Q ` FQg2lell Rd city L11+�R13 Lot Sze Ir, btl� PM Job Address � �� Phone i Ownei s Name fna--CG1� --- Address , 39 .J phone is\ Address ' "5 E (Ylta et1• License NO. 36 2,61%it , i, Contractor 4f..,,-�. TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTNER ❑ DISPOSAL FLD." PROP: LINE DISTANCE TO NEAREST: SEPTIC TANK t SEWER LINES �-------x---•-----rl FOUNDATION 1 "-�GRlCUCfURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial— ,-.--__C_Open Bottom C Manteca t Die. of We"Excavation—� -. Die.of WONCastrlg — 'Type of CadngSpecifications a C,Domestic/Private - ❑ Gravel Pack ❑'I fact Type o1 Grout_ -- t1 pubes f l Other 71 Delta Depth of Grout Seal I I Irrigaran Approxi Depth I I Eastern Surface Seal Instilled by Repair Work Done C Type of Pump H.P. Slob Work Done *, t- Well Destruction ❑ Well Diameter Selling Ailaterial (top 501 Depth Filer Materia(Below 5011 - "+ { TYPE OF SEPTIC-WORK: NEW INSTALLATION - REPAIR/ADDITION I I DESTRUCTION I I eNad bk,wsyst -pfttim 200 ermitted if public sewer is Installation will sane: ReeidsrlPe�..�Comrterci I � Ot�her ,I Number of living units:_ NtKnber of 1— X7' i r t - •s t - Water table depth Character of soil to-a dep4h of 3 feet t h� . SEPTIC TANK B Type/Mfg _ __ Capacitye._ No.Compartments I . Method of Disposal PKG. TREATMENT PLT.❑ �• . M. 1 Dlibrtos b rtserait:' Wall o`uhdetltirta - . Property Line l r LEACHING LINE i No. 6 Length of Fetus 3—''w40 Total length/size .r FILTER BED ❑ oft"to"met Wei-13t2— Foundat-w"rt V'O ! - 'Pr3party"Liner- -a . SEEPAGE PITS Id Oapth A slu CCt4tan6ar - SUMPS Ll Distance to rmifilt: Well - Foundation�5 Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 have prepared 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 pairnil is issued,1 shah not employ any person in such manner as to become subject to workman's compensation Laws of California."Contractor's hiring of subcontracting signature certifies the foaowing: "t certify that in are performance of the work for which this permit is issued,I shill employ persons subject to workman's compensa- tion laws of California." The eppkcam in st call for squired i sp jots. Complete drawirq an reverse side. p Signed X Title: t!r� - Date: 3-9- 6: .,. FOR'DEPARTMENT USE ONLY L �a - Application Acceptetl DY Dib 'T Area Date ^16 Fimll Inspection M Pit Grout Inspectio Additional Comments: ,-r Stk 4666781 ❑ Lodi 389-3621 C Manteca 8247104 ❑Tracy 6364M Applicant - Return all copies to: Environmental Health Perr,4tlSorAu 1601 E. Haadfon Ave.,P.O. Boa 2008,S*.,CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED CAeH flCi:HVED By DATE PERMIT NO. U INFO . Fa 1121tRIN 11.5190 6 �/ EM N-le t A • i+_�