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a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209)466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED p. o! (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to comtruct and/or install the work herein described. This application is made In compliance with San Joaquin County Ordinance No.549 for sawage or No. 1862 for wom/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 17Z75� k ,L /n "`�-- Lot Size ) PML .. Owners Name . o� "'TA"'� Address � �Q 4 �� Phone 4>6 'v / S 3 3 Contractor's Name �` V License No. 7aZ-/ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT G DESTRUCTION ❑ t PUMP INSTALLATION 13 �"� SYSTEM REPAIR 1-1OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE .... 1_ FOUNDATION AGRICULTURE WELLOTHER WELL- INTENDED INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E 0 Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta ` Depth of Grout Seal Type of Grout' J ❑ Irrigation __Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. I State Work Done Well Destruction El Well Diameter Searing Materiel (top 50'1 N Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted it public sewer is I available within 200 feet.) Installation will serve: Residence VCommercial_ :Other Number of living units:—JL- Number ofk rooms O / yam) (� Water table.depth Character of soil to a depth of 3 feet: Z y SEPTIC TANK &---TYpe/Mfg pacity 1SG0 No. Compartments P PKG. TREATMENT PLT. 11 ��tce I t Method of Disposal ''q cc i 11�l..,�E` Distanto nearest: " Well 'Foundation. Property Line�.L� Q LEACHING LINE 9;1-,No. It Length of linea 40 Total le.ng F`LTER BED '❑ Distance to nearest: Well Foundation_ Property Line cA6V 1 Number SEEPAGE PITS �/Oepth � � Size � 'f( 1� SUMPS 13 Distance to ne_aresc Well / �) < Foundation 1 Property Lina `fir DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done I!accordance with San Joaquin county ordinances,state lawn, and rules and regulations of the San Joaquin Local Health District. •1" Home owner or licensed agent's signature ceftifies the following: "I certify that in the performance of the work for which this permit Is Issued, I shallYtlil- .� empty any person in such manner as to become subject to workmen's compensation laws of California."Contractors hiring or dub-contracting signature cenHlea the following:"I certify that In the parforfnanca.of the work for which this permit Y Issued,I shall employ persons subject to workman's compenaa- f tion lam of California." i' The apditent must call f aire used inspections. Complete drawing on reverse side' _ S�,gnedyrtie_ [late: FOR DEPARTMENT USE ONLY L/ Area Application Accepted by Date ; ler Grout Inspection by _ yte Rnal..jnapeceon by 1 - t r 1 Additional Comments: ❑ Stk 466-Ml-" ❑-Lod1-369-3621—❑-Maritera-8237104-- R Trac', -W6631i5-^ Applicant-Return all copies to: Environmental Hetilth Permit/Servioes 1601 E. Hazelton Ave., P.O. Boa 2009, Slk., CA 9=1 ) FEECK AMWNT DUE 1 AMOUNT REMITTED CASH `RECEIVED By DATE PERMD'NO.- 1 INFO .EH 1i14rREv.10/all j-iS-oo EH IN4