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APPLICATION FOR PERIAIT SAN JOAQUIN LOCAL HCALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (2091 466 6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is 1+^reby made to the San Joagcin Local!Inalrh District for a permit to cc %tinct and Por install the work herein described.Thi!.application is made in compliance with Son Jv aqu,n Cnunti,Ord,nun!!No.'.A9 fnr sewafpt or No, IRG2 for weltrpurnp and iho Rules and ReguWtions of the San Joaquin Local Health Drstricr. �/J - L�[p_,j ---- V City/r(/7N.LG4/1 Lot Sira—_'"'�-O •/- ifc LfS PM .Jeb Addrnss .. l �----- /��_- —� � +F / --S_AME_--��----'��"✓�. Phone Owner's Nama ._C7.4LiE_RN_/.2uC �—✓�,>'��C-S— Address - � tf r _ f.rOLt! s GG 7 5� //�� A4dres,. s�W/ec Liccisc No. F ure Contractor 7c+L�,Q7� !'i9 ,--- — k 1,�111 .TYPE OF WELL/PUMP: NEW WELL I.I WELL REPLACE D DES'I'.UCTIO^' t,i S ix PUMP INSTALLATION f_1 SYSTEM REPAIR n OTHER ❑ { j' — DISPOSAL FLD._—_ PROP.LINE o`• .- DISTANCE TO NEAREST: SEPTIC TANY. _ SEWER LINES _. _ '.,. _�_,. —_ PITS/SUMPS r+a� FOUNDATION __ _AGRICULTUPE WELL _-- OTHER WELL _ r ; tit ------- -- ---- —`" _' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ Dia.of Well Casing �!„}; l I Industrial_-_—. ODon Bottom (.�Manteca Ora.of Well Excavationmi Specifications Domestic/Private LI Gravel Pack Cl Tracy Type of Casing_ — Type uGrout_._-- I I Public I.1 Other I 1 Delta Depth of Grout Seal _ - ��'V'-I 1 luigaiion- - Approx. Depth 1 I Eastern Surfate Seal Installed by— Repair Work Done (J Type of Pump _— H.P. State Work Done— 1, Well Destruction- (7 Wea Diameter _.—.__ Scaling Material flop 50'1 ' Depth_ Filler Material(Below 501 r TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION DE`�,TRUC.TION 1 I (No septic systurn permined't public sewer is r available within 200 feet.) "r ) Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms—s�_ Water table depth Character of soil to a depth of 3 feet:_�.iL`/��-- — No. Compartments SEPTIC TANO Type/Mfg K Capacity----- ! _� Method of Disposal, ATMENT PLT.f-1 PKG.,TREFoundation— �/GLZlroperty Line—• 1 L, Distance to nearest: Wall_.�O_�_ +A- ri. Q , c f• Total length/size__... u�P:/,� Q-- ,v LEACHING LINE Cl No.&Length of lines r ----— / — /S X az�Y y - �0 Foundaton—_O��— Property Line FILTER BED O' Distance to nearest: Well {1 ` 1 I DuPth _�t� Size_mss--Z Number SEEPAGE PITS — UM (a Distance to nearest: `Nell._ foundation—,25-�-,_ Property Line DISrOSAL PONDS El I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws.and and 4 rules and regulations of the San Joaquin Local Health Diltrict. - Home owner or licensed agent's signature certifies the following:"1 certify that in the performance of the work for which this permit is issued;)ting,shall not U' employ any person in such manner as ro become subject to workman'e compensation taws of California."Contractor's hiring ct to workman's c sig UW , ,t employ the followin cartil that in It*Pectic,malice of the work for which this permit is issued,I shall employ persons subject to workman s compehsa 1 g:„ Y 4 tion laws of Calilo a ` -•II -�i1C olsoecGons.Complete drawing on reverse side. The applicam mu. — TCe�yTR/�L�O ate. 1.- Signed X _ Title: - J n v- ,p. G /f j lY FOR DEPARTMENT USE ONLY Area Data ¢^ , ADP+`cation Accepted by vT Oete DateInspection Final Pit or Grout Inspection byr t — a Additional Comments: "f+¢ D Six 4666/91. Lodi 364.3621 O Manteca 823)104 ❑Tracy 835-6385 �7 Applicant•Retum all copies to:Environmental Health Permit/Services 1601 E.Hazelton Ave..P.O.Box 2009. Stk., CA 95201 4F I ,a AMOVNT REMITTED CK RECEIVED BY DATE PERMITNO. ^ FEE AMOUNT DUE CASH ' INFO EE �O ,ed x�y,L N 13-24 IREV. 7d � + F y.eye - FH 14'n .t. d pY AVYq 7 Y 5 . t t t 4.� A,1D