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r APPLICATION FOR PER.-AT 0 SAN JOAQUIN LOCAL HEALTH DISTRICT ?:,; ? 1601 E. HAZELTON AVE., STOCKTON, CA F Telephone (209) 466-9781 �; I= PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described."-tis application is mads,in compliance with Son Joaquin County Ordinance No.549 for sewage or No, 1832 for well/pump and the Rules and Regulations o•the Sarrrttt,,,)))oaqu' t. Local Health District. i a Job Address _ � �_- {a! � _� � City_W'1)C-4_ Lot Sire PM `rte owner',;Name—P-9--&—k- G:Lc✓c;2_ Address _ Phone 4 � � �1 � License Ho. ' °norte TYPE OF WELL/PUMP: NEW,WELL 0 - WELL REPLACEMENT LJ DESTRUCTION 0 PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LiNE FOUNDATION_ AGRICULTURE WELL , OTHER WELT PTTSlSUMPS • �' uk''"" INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; Lt Industrial ❑Opon Bottom a Manteca Dia. of Well Excavation Dia. of Well Casing � ❑Domestic/Private ❑ Gravel Pack ❑ Trac_ y Type of Casing Specifications G Public C Other C Delta Depth of Grout Seal Type of Grout I a 0 Irrigation —Anprox. Depth u Eastern Surface Seal Installed by� iE J Repaii Work Done Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material(Below 50') , TYPE OF SEPTIC WORK: N°W INSTALLA'ION REPAIR/ADDITION i] DESTRUCTION C'i (Nu,septic system permitted if.public server is available within 200 seat.( J ( !# Installation will serve:' Residence 'Comm'ercial_ Ther ; Number of Ilving units:1L__ Number of bedrooms r CC f{ j Character of soil to a depth of 3 feet:_ y1y�_}�fid " Water table depth 3 di SEPTIC TANK TypelMfg Capacity_-//(lZ2_ No.Compartments g; PKG.TREATMENT PLT.i'. Method of Disposal -.00R) Distance Io nesrristr WetIl(Jt^y Foundat en Jf�r Property Line 2;12 P� r` t � LEACHING LINE y No. & Length of lines 1'`'_, 4 r ._Total length/ _ FILTER BED C` D;stanee ra nearest: Weil /�! Fcwndation,-;3d Property Line-_/6�T `'+`.,t t•, t ii ' dE SEEPAGE PITS ❑ Dopth /d F ' Sire� _x!v�' , `—Number ¢ SUMPS Distance to nearest: Well o1G C-F,undation F*�Property Lir.a 7 r ' J DISPOSAL PONDS L'r � '- I hereby certify that I have prepared this application and that the work will oe done in accordance with San Joaquin county ordinances,state la-Ars,and rules and tagulaliort of the San Joaquin Local Health District. Home owner or licensed agent's signature Cert•„lies the folowing:"I cenify that in the performance of the work'furi which this permit 1s i".d,'I.hal1 riot F ' g ' ';; employ any psrson in such manner as to bocame subject to workman's cbmpenro6on taws of California."IContrettot s hiring or sub Contrecttng signatur0. "f =entities the following:"I certify that in the performance of the work for which-hit;permit is issued,I shall employ persons subject to workman's compensa- `. # tion laws of California." - -- r. E The-applicr rit must call for all required inspections. Complete drawing on revere side. ' Signed?L. 1� Title: e ,I� ''�C� Date: /O'��— si FOR DEPARTMENT USE ONLY I€ Application Accepted by Date Arai~ I Pit or Grout Inspection by -- Date_ Fi I InsDectlOn by Data�Sl�_�t t: PP,, Additional Comments:f II `i Ls Stk 465b M L..],,Lodi 3FA-3621 C Mantervi M.7104 Tracy 8356385 Applicant• Return all copies to: Er.Nirormenlar Health Permit/Services 1601 E. Harelton Ave.. P.O. Box 2009,Stk:,CA 95201 I FEE AMOUi,i, DUE AMOUNT REMITTED CK a —r-�� RECENED BY DATE PERMIT'No. FO CASH i CM I<7S f - a