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APPLICATION FOR PERMIT SAN JOAQUIN.LOCAL HEALTH DISTRICT t,:! 1601 E. HAZELTON AVE., STOCKTON. CA Telephone 1209) 466-6781 t�"e PERMIT EXPIRES 1 YEAR FROM DAT: ISSUED ' (Complete in Trippcate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein devviber.This applicatwn a l)' tmade In compliance with San Joaquin County Ordinance No.549 for sewage or No.1382 for well/pump and the Rules and Reguations M!M San Joaquin 1 e Local Health District. : jr Job Address y 3 a OCiry _ '_ct Size 1�'_.L'=A.3rM Ownei s Name I— R-G L I) W INF I N Ttldr� 7 -7O J �. /.elS�k/E'Nd _ Pnone u ;,'.a. Ccntrector s Name L0, 1'C � License No. _ Phone 34i Ty PE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT G UESTRJCTIOh v s�,*xby a ttgv�e/lar PUMP INSTALLATION ❑ ` SYSTEM REPAIR ❑ 07H D'STANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FCD._ FRCP. LINE & O FOUNDATION AGRICULTURE WELL_ OTHER WELL _ PITS/SUMPS '^'! INTENDED USE T.PE OF WELL "PROBLEM AREA -' CONSTRUCTION SPECIFICATIONS 1 Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation _ Dla.of WellCasing. Dourest c/Pnvate : ❑ Gravel Pack ❑Tracy Type of Casing Specificatlons 'rn ❑ Public ❑ Other O Delta '- Depth of Grout Seal Type of Grout ❑ Irrigation __-Approx. Depth C1 Eastern Surface Seal Installed by_ _ n Repair Work Done ❑ Type of Pump H.P. — State Work Done r Well Destruction ❑ Well Diameter - Sealing Material(top 50') Depth Filler Material(Below 50') 7YPE OF /WORK: O W INS AL TION SN SEP(IR[6QDITION O DESTRUCTION INo septc system permitted if pubic sewer Is I pn ' ��JJ�t''ll avellable within 200 feet)_I Installation VIII serve: Residence_ Commercial_ Other p (,_a-G!� W I T 17 Number of living units:_ Number o droo f Character of soil to a depth of 3 feet: _Wa!er table depth SEPTIC TANK ><TyproMfg 19 No Compartments PKG. TREATMENT PLT. ❑ - � Method of Oispasel Distance to nearest: Well Foundation_ Property Linef' ° } r !� f _FACHING LINE C No. B Length of lines —L: ,� � --. gth/sz b FILTER BED ED Distance to nearest: ' Wetl F atidn Property Line �° hx SEEPAGE PITS C1Depth _ Size _ Number ' SUMPS ❑ Distance to nearest Well Foundation__ Property Line " SPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work wilt be dans in accordance with San Joaquin county ordinances, state bws arc rules and regulations of the San Joaquin Local Health District. I <. Home owner or licensed agent's signature unifies the following:"I unity that in the Performance of the work for which this permit Is issued, I shall not employ any person in such manner as to become subioct to workman's compensation laws of California."Contractor's hiring or sub-contracting signature '. certifies the following:"I certify that in the performance of the work for which this Permit is issued,131xll employ persons subject to workman's compsn" tion laws Of California." - - Theapp1mucell forall re ui d inspectons. Complete drawing on rev' side. S.gned - Title: wA FOR DEPAR MINT USE ONLY Application Accepted by Cate J L7�//�� Pit or Grout Inspection by _ Dale Final Inspect on by �Jl%�Sf '-_.____ a e ✓v Adcitional Comments Stk 466-6787 ❑ Lodi 369-3621 ❑ Manteca 873.7104 racy 835.6396' - Applicant- Return all copies to: Environmental Health Permit/ServiceA 1601 . Hazelton Ave., P.O. Box 2009,Stk., CA 952131 I�FEE AMOUNT DUE AMOUNT REM TTED C SH RECEIVED BY DATE PERMIT 40 IN eH tax