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AX N qq4d APPLICATION FOR PERMIT SAN JOAQUIN LOCACHEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA it Telephone (209) 466-6761 rt PERMIT EXPIRES'1 YEAR FROM DATE ISSUED (Ccinplete in Triplicate) Application is thereby made to the San Joaquin Local Health District for a permit w construe'and/or install the work herein dewdbed Thh applkAtbn N a made in compliance w th San Jdr n County Ordinance No.549 for sewage or No 1862 for well/pump and the Rules and Regulations,of tM San Joaquin v Local Health District Job Address `'f�3��;tiN�_ - c'N Lot sae V oAddress,Owner's Name Phone HxA CCC5�'vE..• , ,line Contractor --4 /—/i(�/%2_Address r• Da '�RL/S/4 License Nook_ .Phone TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION G PUMP INSTALLATION ❑ SYSTEM REPAIR❑ OTHER ❑ r ' SM DISTANCE TO NEAREST: SEPTIC TANK SEWER TINES DISPOSAL FLD. PROP LINE _ Js, _ - FOUNDATION AGRICULTURE WELL OTHER WELL__ PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS / ,} ❑ Industrial ❑ Open Bottom - ❑ Manteca Dia. of Will Excavation Dia. of Well Casing ( I' =' Domestc/Private C Gravel Pack ❑ Tracy Type of Casio Specifcaton ik i L. Pubic ❑ Other ❑ Delta - Depth of Grout Seal.`_ Type of Grout t 'Y ❑ Irrgabon '--APProx. Depth C1 Eastern 'Surface Seal Iratalled by_ Repair Work Done L' Type of Pump H.P. _'$taxa Work Dona Well Destruction-. G Well Diameter _ Sealing Materisi ttcp Si Depth' - Filler Mat,rial(Below 50'1 rm TYPE OF SEPTIC WORK: NEW INSTAL(ATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is n� dsa labia within.200 fee Is w Installation will serve ResideriCommercial _ Other / w .Number of living units --I .Number of bedrooms Character of wll to a depth of 31eet:_ S-/fh/bl/ is-A r✓1 Water table depth_�G1 SEPTIC TANk- i Ey7- Type)M(g _p _ _ Capenry_�,_ No. CompartmenC. �2_— I5 PKG. TREATMENT PLT a �^ fT-. Method of Dispoaol t '-3 Cyt Cistance to nearest] Well Foundation__Q_ Progeny Lina LEACHING LINE - ❑ No. 3 Length of lines 'Total length/she_ FP�TER BED ❑ Distance to nearest: WRII Foundaton Property Lie :SEEPA6E PITS L2 Depth Size Number T w�"yj SUMPS ❑ Distance to nearesa Well FqundaCon Property Line t DISPOSAL PONDS ❑ - ' •r I say 3 Yky ' I hereby certN.that I have prepared this application and that the work will he done in accordance with San Joaquin county ordinances state laws rid !- rules and ragwatici of the San Joaquin Local Health District. '•t. ..Home ii or licensod agent's signature certifies the following: "I certify that In tl-,performance of the work for which this permit Is issued, I sha!!^.ot employ any peraon in such manner as to Lecome subject to workman a compensation laws of C3100rn a."Contractors hiring or suo-contre_rn-&,,,a! re - certifies the forowing:'I came,that in the Performance of the wort for which this permit is Isaund,I shell employ parsons subject to workman's ,;on we of California... The applicant must cell or 11 quirad 'nspections. Complete drawing on reverse side. � Slpned x Tills, t. FOR DEPA❑TJv1ENT USE ONLY Appllcaton Accepted by — — = fl Date Ar Pit or Grc i .diction by Ca _ Final Inspectio/6- n by _ _ Date Additional Comments:,41LLf111LC(N'y //fG�f-`f !/ - C Stk 466-6781 ❑ Lodi 3693621 ❑ Manteca 827'7104 ❑Tracy 8356385 T 7_r 'j"I Applicant- Return all copies to: Ervironmental Health Permh/Services, 1601 E. Haxelron Ave., P.O. Be,.2009, Stk., CA 95201 WF0 AMOUNT DUE AMOUNT RiiMITTED CASN RECEIVED R� DATE PERMIT NO, /