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l APPLICATION FOR.PERMIT SAN JOAf3UIN;.LOCAL HEALTH DISTRICT ` 1601 E. HA2ELTON.AVt., STOCKTON, CA ' T*kiphone (209)466-678'4 i PERMIT EXPIRES I YEAR FROM DATE ISSUED+' � tt "'X (C6mplBte'in Triplicate) r: ApplicatiOn is hereby made tv the San Joaquin Laeai I1841tb DiMitt for a permit to construct end/or Instal!the Work herein described.This op tion is made in compliance with San Joaquin County Ordinmios No.643 for sewage or No.1862 for was/pump and the Ry!a&f lens of the San Joaquin .Local Heatth District. .rfi •r-{' Ar;Di; K ''�'"'' f ° r •~ V, F' ,••..... �, .rli�Y' lie Job Address14 City .r'pot'Si:e PM {.1� r r. .,• ..y .} `r - -4 ,,R• °' r"'rl� •:mow. Owner's Name Qa k"A„#£.r•n Address`'• � _� - - -Phone I $w• q,6 r- /;fx-R. +��— 't4 a` r _License No. Contractor Address . Phone -- 'TYPE OF WELL/PUMP: NEW -WELC-0-- ”" WELL REPLACEMENT Cl DESTRUCTION ❑ �+ PUMP11Wi4LLATION ❑ _ SYSTEM REP_AIR,❑ OTHER d DISTANCE TO!NEAREST: SEPTIC TANK ~SEWER LINES 1D F(OSAL FLD. PROP.LINE . ^+ FOUNDATION" AGRICULTURE WELL OTHER WELLI7SISIJMPS 4 INTENDED USE TYPE OF WELL PROBLEM AREAr CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom E;]Manteca Dia.of Well Excavation Dia.of Well Ceairtg ❑ bomestic/Private ❑ Grave!Pack' '•'TO Trecy' """ Type of Casing Specifications ❑Public ❑Otho ❑ Delta Dapth of Grout Sea! Type of Grout ©Irrigation ._AtfProx. Depth ❑Eastern Surface seal Installed by _ Repair Wolk Done ❑ Type of Pump H.P. State Work Done -CC" Well Destruction .❑ Well Diameter Sealing Malarial Itop SO G Depth Filler fMateriai SOIOW 507' TYPE OF SEPTIC WORK: NEW INSTALLA�TIONEPAIRIADDITION DUCTION ❑ (No septic system permitted it public sewers available within 200 feet.) ` 1nstaliatlon will serve: AenCs_ Conusercial Other' ► � Number of living.units: Numberlof bedrooms - �'^ _ • t t ChwaCt9F of soil to a depth of 3 feat: + T« Water table death r, SEPTIC TANK I'r Type/Mfg ~Capsclry No. Comparur";�s ' ! PKG.TREATMENT PLT.Q �' L'� - Method of Dispose i Distance to nearest:yY,;iWell b .�6gnlldon 1 d t Property Lina LEACHiNG-LINE aKNo.&Length of fines -Total length/ FILTER BED ❑ Distance to nearest:~ Well Foundation k Property Lineal SEEPAGE PITS I Depth '�'S r Sita :.. Number E sumps � ❑ Distance to r��rest Well ;kpm _ Foundfitinn AL* .Prope�ry�int f.i. ,t.1 „r,,��'� •..»•" I! ['DISPOSAL PONDS' ❑ s I hereby certify that I have prepared this application and that the work will be done in accordance with San,46aqulin couniq orduiences:stata'laws,and j. . rum and nrgutations'of the San Joaquin Local Health District. ;� •k H"owner or,l� n6id`aga&s signature cartifrecertify that s the folovAng:"I cerin the performance of the work for which this pemdt is issued:I shell not - f employ any person in such manner as to becorne subject to workman's compensation Jaws of Califomia."Gontractors hiring or sultoonvaeting signature +; des the fallowing:"I certify that In the performance of the work for width thI6 permit Is hwied,I shall srinploy p4reons subject to workman's comperwv,"T13'1- i tion laws of CaMomia." The app must call for all required insrDactlons.Complete drawhtg on reverse aide. i Signed o - Title: �r'G� '` Data:��`° �"" atr i { DEPARTMENT-USE OXi i A Iicatibn Accepted by �-- R .�� - Date-4 Pit Grout Inspection Iry + Final lripection ,1 -w:i••I �� I - Additional Comments: + ©Stk 466.6781 ❑Lodi 369-3821 i ©Manteca 1 0 Tracy Jiffs 6388 �� -'' Applicant'-Retiirnn all copies to: EwArd i antral Pewit f7 Servloes 18tH-E.liezetwri Ave.,P.4.8ax G09,5tk:,' +4 1 � `" INFO AmotiNT DUE J AMOUNk-,RENIITTFD CASH RECEMD n. DATE,, PERMIT-w0. r. -� rEH,a-=titEv,risnr ..t �. ��- •ti � �I�$5