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Mfr APPLICATIOf11 FOR PERMIT SAN JOAQUIN LbCAC HEALTH DISTRICT � a 1601 E. HAZE I ON AVE.,`STOCKTON CA - Telephone (209) 466-6781 F_ ' PERMIT EXPIRES 1'YEAR FROM DATE ISSUED i (Cbinplete in Triplicate} "tt ApplicationI' natio i - y pp n s heseb made to the San Y Joaquin E Lace Health i aq District ct for a permit to construct and/or install the work herein described.TMs a i` 1 i cation s 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 5an'J'oaquin Local Health District. F Job Address City-1920061F-0 Lot Size4■.r A—/7:5-7PM' - Owner's Name LY Address Phone ContractorAddress- ense No ZrEW�Pho Rx TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ --�- t PUMP INSTALLATION ❑. SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. CROP. LINE :3W FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS # e INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f l Public 171 Other 171 Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 , Depth Filler Material (Below 501 TYPE OF SEPTIC WORK. NEW INSTALLATION (I REPAIR/ADDITIONX DESTRUCTION I I (No septic system permitted if public sewer is 1 ., available within 200 feet.) Installation will serve: Residence ' Cortun_ercial Other Number of living units:-�,' lUumber of bedrooms ` "`'� Character of soil to a depth of 3 feet: -� Water table depth j °' SEPTIC TANK Type/Mfg _ jCapacity, Na. Compartments PKG. TREATMENT.PLT. ❑ - f Method of Disposal Distance to nearest: Well Foundation 1 t Property Line�[ LEACHING LINE No. 8 Len th of lines r g � Total length/size FILTER BED ❑ Distance to nearest: Well Foundationr J f' tt Property Line SEEPAGE PITS Depth Size Number `} SUMPS Ll• Distance to nearest: Well r + Foundation - Property DISPOSAL PONDS:- - ❑ _... _. { _, Line r 1 hereby certify that!have prepared this application and that the work will be done in accordance with $an J rules and regulations of the San Joaquin Local Heahh District.. oaqu+sa.county or cess stat��ws,and Home owner or lieansed a nature aerUCres the following: , r n `. _. -ge • 919 .--. - w� �. r jl3 g:"1 certify that i»the perfgrmance of the work for which this ss issued Mali not ~ PAY tmY person m such manner as to become subject to workman's compensation.laws of California."Contractoes.hrring or sub• true t. {; Certifies the foNowing i certify that in the performance of the work for which this permit is Issued i shall employ persons sub' to wvdu�taa tion laws of Cairtomsa : siaorrtpense- �- The applicant must cap for ail required stspectw`is. Co mplat sawing ori reverse side 4 Signed Tole elf Dat e N -DEPARTMEW USE ONLY ! r Application Accented by rlspectiari by kPrt or Grout Date I y , Final lnspecdort ft file Cpmrnents: `w x rs.•:i'r .. - �' _ '�, I #, - r +y.7 tec r I 16B-6/8t r `� Frodt 369- 82rt e;0 Ma face M7104 7 s w� -APplicatit -_ Ilio EtnrlronttbrtfaL - �]t,,�T._ - �- .- t601+I:�l<a } e!t ri Ave PJB.60x 2A09�Stir l'.A 9'01... E ermlt/+�eNICBS q a f NT AEhtFTTEa CA,kl� REC>:111ED TE _ 4A r.. aa. 4'+;.- .=,19 =�r�L.%7• ..G 1•.1:'A y.F'.'f ��_"' Y ., � .. .._... - A�: �. ',i,�'h" r. _ . r