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APPUCA r ION VOR PERN SAN JOAQUIN LOCAL .'IEALTH DISTRICT 1601 C HAZr—'C)N AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is herehv made to the San Joaqua Local Health District for d permit to construct and/of install the work herein described.This appGcetirm i7 made in compl'ance with Son.loagvm Counry Orali.tancu No 549 for sewage or No. 1862 for well/pump and the Rues and Regulations of the SAn nz tU;" Local Health Uis((tnc/It��. 1/� �( I rl� O _—: J — Int Sire� 2013 f PAA Job Address _ —__—_ _ I t O ►-1@bbs Address Phone Owner's Name ..__ -.____ `•�{�Co+�_Address� _O Ig�JNK�__Licence No.29 lr\Phane3'��i Contractor�.)M_.___-- - ---- r TYPE OF WELL/PUMP,: - .—.•NEW WELL :.I _ WELL REPLACEMENT Ll DESTRl1CTION L7 PUMP INSTALLATION C SYSTEM REPAIR CI OTHER D _- SEWER LINES DISPOSAL PLD. PROP.LINE'--. DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS —_ --- FOUNOATIO_N AGRICULTURE WELL __— OTHER WELL_ _ INTENDED USE TYPE OF WELL PROBLEM AREA C_ONS'fR_UCTION SPEGFICATIONS Dia.of Well Cii,rng 7 Industrial I:1 Open Bottom (-IMantecaDia.of Well Excavation Specifications rype of Casing_— I.7 Domestic/Private C7 Gravel Pack Il Tracy Depth ul Grout Seal _ __ Type of Grout_ FI I Public Ll Other it )elta —uul Installed bV_ _- I I Irfigatlo __n _ Approx. Depth I I Eastern Surface S —__ H.P. Stattee Work Done Repair Work Done 11 Type of Pump Sen!'nq Material(top 50'1 -- Well Destfuction Il Well Diameter - Depth Filler Material(8,010wG 501 -- TYPE OF fiLPIIC WORK: NEW INSTALsystem LATION I I REPAIR/ADDITION I✓ DESTRl1CTION I ;No availableiwthin 200 feet-1crf if publir,sewer—is Installation will servo: Residence_— Commercial__ Other__._.........—._._ Number of living units-__ Number of bedrooms__.._.— - _ Water table depth Character of soil to a depth of 3 Get:— _ Capacity._ —__�No. Compartments SEPTIC TANK f.7 Type/Mfg --- MLn hd f Disosal PKG.TREEATMENT PLT.❑ Pro rtDistance to nearest: Well __ foundation tt^ V Total length/sizLEACHING LINE I.1 No.8 Length of lines _ pro rtFILTER SED LI Distance to nearest: Well Foundation Pe 1V _y SEEPAGE PITS IaPth -- __ r0 r _ Propert3» Distance to nearest: Well ls� Foundation ttt SUMPS DISPOSAL PONDS I1 - } I hereby certdy that I have prepared thin application and that the work will be done in accordance with San Joaquin county ordi,tances,state Wes,and ales and regulations of the San Joaquin Local Health Distract. I shalt not Home owner or licensed agent's signature certifies the following: certify that in the performance of the work for which this permit o issued. employ any person in Such manner as to become subject to workman's compensation lays of California."'Contractor's hiring or sub-contracting signature certifies the following:-I cortify that in the performance o1 the work for Which W. permit is issued,I;hall employ persons suhpct to workman's corneansa- r tion laws of California." icl The applicantmu all for all raquireA iniuns.Complete Arawing or reverse side.Title: Data: _ a� r Signed X_ ; FOR DEPARTMENT USE ONLY \ Applictrtion Accepter by — _ Final Inspection by Oete� Pit or Grout Inspection by — Date_-- Additional Comments:'• -- C Stk 466-6781 0 Lodi 3693621 C Manteca 823.7104 L7 Tracy 035-6385 -I",Stk., 15201 •,- Applicant-Return all copies tu:Environmental Health Permit/Services 1601 E. Hazelton Ave.,P.O. Sox ~ CE RECEIVED By DATE PERM'Y NO. r,.. FEE AMOUNT DUE $,MOUNT REMITTED H INFO - FH UN InEv,i i••,, 14 N