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APPLICATION FOR PERMIT • SAN JOAQUIN LOCAL HEALTH DISTRICT 1661 E. HAZELTON AVE., STOCKTON, CA u Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED { (Complete in Triplicate) Ilcation s Application a hafetry made tq the San Jce quit Local Health District for a permit to construct and/or install the work herein described.This app made compliance with San Joaquin Cou Ordinance No.549 for sewage or No. 1862 for well/pu Tip and the Rules and Regulations of the San Joaquin at Local Health District. - A C ILA 7 PM t11 nt /1 ►� I. DYSq cityLot Size Job Addressrrr�� "A /� LLA"-- dress &A&Kp hone ) dress �------ OwnersName Y>. . . f-, �`.��✓ r E.+1+.r s,,a�`ec1^^+ � (2Phone Address -1111d 0�� License No. Z —ZIP 3bS-S(oS I ; Contractbv'r`�' WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPE OF WPUMP: - NEW WELL ❑/ OTHER ❑ d'IF SYSTEMJiEPAIR ❑ 6 PUMP 1NSTALLATI0 k7 i PROP. LINE 1` DISPOSAL FLD. DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES OTHER•YYELL ' gJTS/SUMPS - 4 -- % / GRI.CULSU_)E WELL FOUNDATION. c t , INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS{ Dia of Well Casing . ❑ Industrial ❑ Open Bottom �/0 Manteca ` Dia. of Well Excavabon .. , 1 t ,'a Specifications ❑ Tracy : r\ Type of Casio^ ❑ Domestic/Private ❑ Gravel Pack Type of Grout_ .�y..; lu. ❑Other/ ❑ Delta 71 Depth of Grout Seal I'1 Public I !✓ 1'`� •� -j. JIaF _Approx.�Dai'pth I 1 Eastern Surtace'Seai Installed W I I Irrigation State WO* Done_�`f Repair Work Done ❑ Type of Pump H.P. - ' Well Destruction ❑ Well Diameter — Sealing Material(top 50'1 Depth ler Material (Below 509 available within 200;1eet.) TYPE OF SEE7JG WORK: NE lN$TALLA iT, N-11� : 5 ADDITION DESTFILCTION I;1 iNo septic system.pees ittad,iA,pu6lic sewer Is AnstallaGdn wiil'serve;. Residence_ Comm_ercia�l-� { ' " - + units: + '"-Number d uom Iy V Water table depth If ving Number of li I Character of soil to a depth of 3 fall ' _ No. Compartments i i .i.'+Y CapacitYt.�. SEPTIC TANK ❑ Type/Mfg r / ` , r Method of Disposal PKG.TREATMENT PLT.❑ lid, 1 Line ' F Foundation t — Property 1 4 DLstarrce.to nearest: Well 1 V ' ti3 I Total length/slz LEACHING LINE r ONo. &Length of lines po�1i dation Properly 11 FILTER RED j 43 Distance to nearest: Well { N mbar A r SEEPAGE PITS S16pth $� r UrT Property Line -- Foundation�� SUMPS ❑ Distanceta nearest: -..Well Foundation t DISPOSAL PONDS I +A I hereby" -ty that I-hal prepared this application and that the workNvill��hone in accordance with San Joaquin county ordinances,state laws, and rules and regulations of the San Joaquin Local Health D3trict. i Home owner or Licensed agent's signature certifies the foliowing:"I ceruh'that intha-pe!�ormance of the work for which this permit ontr u in i shall not employ any person in such manner as to become subject to workman's compensation laws of Caldomia."Contractot'a hiring or aDcenbs n's c signature certifies the following:"I.cemn that in the performance subject t the WR for which this permit is issued,I snail employ Persons subject to workman's compensa- 1 il tion laws of California."; + f,, ( The applicant call fOr a ui d inspections. Complete drawing an revers Sids-('1 w Date: 1�+ Title: \\1. N Signed X 1. --FOR'DEPARTMENTVSE"ONLY'" f __�- _\ _ .. Area IIII _ Data / Application Accepted by pate T Final Inspection by tl or Grout Jim don by�� ..� vAdditional Comments: O Manteca 823-7166 ❑Tracy�fYiS• Stk., CA 95201 i ❑ Stk 466.6781 ❑ Lodi 369-3821 P.Q. Box 2009, Applicant- Return all',copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., s �r. INFO MOUNT DUE AMOUNT REMITTED CK PEEER/ED BY GATE PERMITNO. CASH •..A rn 39 k r.EH 13211REV.i/851 � f' � w 1 ER 1426