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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ' . y •� ..spy r 1PERMIT EXPIRES 1-YEAR FROM DATE ISSUED !J. (Complete in Triplicate) - Applicatlan 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 ( 9 7 S_ /Y z //S/ l��L. City 40ri Lot PM Owner's Name.,V.y'o CyI.L�L> 1 $Address 7� 7'5 N i S I lt, ,D� Phone •� 1 Conhacttx ress 'IE"erSY Nb`E '9 �YY�•Phone�- - TYPE OF WELL/PUMP: NEW WELL,}' WELL REPLACEMENT ❑ DESTRUCTION ❑ ++ - 'PUMP INSTALLATION, SYSTEM REPAIR ❑ J- OTHER O 7 i •DISTANCE TO NEAREST: SEPTIC TANK 66 / SEWER LINES _ DISPOSAL FLD. PROP, LINE 3Q FOUNDATION AGRICULTURE WELL' OTHER,WE — PITS/SUMPS - "�INTENDED USE TYPE OF WELL PROBLEM AREA CONS YMUCT10N SPECIFICATIO ISS r r nstrial du $Open Bottom ❑ Manteca_ �'Di2. of Welt Excalattig ioon Dia.of Well Casi �e >] Domestic/Private O Gravel Pack �+El }racy' Type of Casing S /NO^l Specifications �1 Publicrp,t• ❑ Delta Depth of Grout Seal f t ^Type j� Grow Irrigation /0.1.:Appros. O%th �1 Eastern Surface Seel Installed by l`' rt!(AY / ,21 t hepair.Work Done 0 Type of Pump U H.P. /f - State Work Done Well Destniction• t TT—Well Diameter Sealing Material(top 601 f •` , j - Depth Filler Material (Below 501 TYPE OF SEPTIC WOFIK. NEW INSTALLATION(1 REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted it public sewer is { "^s available within 200 feet) } Installation will serve: —Realdence_r Commercial_ Other Number of living unity: Number of bedrooms 1 , Character of soil to a depth of-3 feet: V Water tabb depth 1. y '! SEPTIC TANK 'P❑ Type/Mfg t Capacity No. Compartments 1I � PKG. TREATMENT PLT. O � , Method of Disposal ' • Distance to nearest: Well Foundation i, + Property Line 1 LEACHING LINE Q No. 8 Length of linea }Total laIngth/size I FILTER BED . 7` O, Dista;ado,nearmt: Well FoundationL --Property Lim '1' r 1 SEEPAGE PITS I I Dedth Size Number V' SUMPS ❑ Distance to nearest: Well Foundation Property Line , ,. DISPOSAL PONDS EJ - - 1' j I hereby canify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinenced, state laws. and rulas and regulations of the San Joaquin Local Health DiWict. ; { _ Home owner or licensed agent's signature canities the following: "I certify that in the performance of the work'for which this permit iy issued,'I shall not J employ any person in such manner as to become subject to workman's compensation laws of Califomis."Contractor's hiring or sub-contracting signature certifies the following:"I canify that in the performance of the work for which this permit is issued,t shall employ persons subject to workman's compensa- tion laws of California." The applicant at call for all required inspections. Cromplete drawing on reverse sl f yI Signed 6/11)Jdpit n n w Li 9Q Tide: Date: r FOR DEPARTMENT USE ONLY Application Accepted by L Date ��1�~ 1 Area At or ro Inspection by ; Data DateJ � Additional Comments: , O Sir 466.6781--1 35936211 O Manteca 823-7104 ❑Tracy 6766985 f App5c6n - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 •� 1 1 FEE NFO AMOUNT DUE f AMOUNT REMITTED WSN RELER/ED BY DATE PERMIT'NO. 1 •.EN I1N IREV.veerA. Ell �f EN 14pa (�