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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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/W Install the work heroin described. This application is ,Wade m compliance with San Joaquin Co,.ity,Ordinance No.549 for sewage or No. 1862 for walUpump and the Rules and Roqulations of the San Joaquin Local Health District.Q/ PM Job Address L /_l/1^ / � `` a`' City�t $X Lot Sire led Owner's Name ---- A/d�dresa [�• Ph.. d 4C ..n ld Addres3 �L' License No. Contract TYPE OF WELL/PUMP: NFW WELL 0 WELL REPLACEMENT LI DESTRUCTION ❑ \ PUMP INSTALLATION U SYSTEM REPAIR ❑ OTHER O DISTANCE TO NEAREST: SFPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION - — AGRICULTURE WELL _ OTHER WELL PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA C_O_N_STRUCTION SPECIFICATIONS_ InWntrW _-- I , Open Bottom I 1 Manteca Dia of WON Excavation ----_-__ Ole. of WON Ca" Domestic/Private Gravel Pack 1 1 Tracy Type of Ca"— Specifications P,rMtc 1 I Other I I Delta Depth of Grout Seal Type of Grout--- - lrtrg4tmn Aly«nt nri,th 1 I fntern Strrloce Seal Installed by - Repaa Work Done i I Type ut P,rmp __ H P _ Slate Work Doll _. Wali Destruction Well Drarrr,- _-_ _ Seating Material(top tit)•) Depth ---- Filler Material(Below SO') - TYPE OF SEPTIC WORK NI W INSIAI 1 AT CINK REPAIR/ADnITION 1 1 DESTRUCTION 1 1 INo Septic sysm"per+�tied N pubic sewer is InsteNatien will serve Residence rroil Coettial .— Othef —___-._-- wadable withtNn 200 he1.1 ! Numb•i of I^^ng unlit J__ Mimi-of ' Chatactn-of so,$to a depth nl]tent — Want table n r depth �� Ti� No. Comparfrwt t SEPTIC TANK CtpaY � PKG TREATMENT PLT. I I / Method of�7tDierlosal Distance to no-moat W Foundation -1�_ PropeliY LMS- +�-- LEACHING LINE ;✓Nn r< 1 engeh of lees _-- TIN lentglh/e1EeJ e1L- - i FILTER BED Uralara a tri rie4rest Well..if'�Q...- Foundellon _ fJd Plopef V line�- SEEPAGE PITS L� n«pili Y`a _ _ St» J____— — ' `_ - SUMPS (bM.in,«W'Wale it WN �,(:— Fouritla im ._-7d.__— P►opatY I�--�-++-- DiSPOSAL PONDS _ 1(Wetly CW,ty that 1 hjve{neliared th,1 49Ipi,e Icon and that the week was be done on accordance with San Joaquin county ordNences, 114116 laws, and rules and ralltr4tons of !M San Jnaqu.n ltxat l400fth District Home owner,of licensed al7rinl's vjInatieto rert,fys the lol of wio;I: "I certify N at in the performance of the*Wk for which this pwmil is issued,I Mill not wrrpibY any Wootton such rNnner at to holwwme sulitect to workeneri s CortlpaM6tlon laws of camorm,"ContractWs 1tMrng or sub-cOnhactitlg signigh" carates the toaowirq "1 certify that on the parfewmarnc•of the work IW with leis pm n! is inured.I SW•rnploY Pat aote sublecl to worktt»n's torrtpaee tion laws of Caldorms" The eptnlicant mus N IW ale rogjord•njp•chons Comr+ral•drawing on reverse aide, �,f Q 11-{ t : Il.'L Tiffs: _�—Y I ,.- Dv1 t 2`0 V �'J ' Signed x. - --- c-T FOR DEPARTMENT U11 ONLY Apcatoept n Acced M Delispli Grout Inspection by �•Q / .•� _ Dat• FiW InaOection by D Add,fonM Comments - St► 4666781 1 Lodi 30Y,21 ;: Manteca W3 7104 C7 Tracy M638S Appnrcan, Ra/urn NI Copses to Env,ronmwntN Health PMmI/Sa.vrcN iWl E Heratton Ave. P O. Box 2009, Stk., CA 96201 IEE AMOUNT Otlf AVOVNT t1EMITUDPECEWID ev OAT! /[ami too Off • tet 1)ra,arV -• � � / f M It rA