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v.. APPLICATION FOR PERMITO�M SAN JOAQUIN LOCAL HEALTH DISTRICT �J 1601 E. HAZELTON AVE., STOCKTON, CA f Telephone 12091 466.6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ~ (Complete in Triplicate) - _ .+ Apphcaiu,r,is heiaby made to the San Joaquin Local Health Distract for a permit to construct andlor Install the work herein described.This application as r=,ut,r n,r.Gmi,hNlnca wilt,San Joaquin County Ordinance No.549 for sewage or No. Ih62 tur w„grpump and the Rules and Regulations of the Ban Joaquin it t c.cdl tfeairh Msmct. s x, Adflwss �+ k, �_,. City h 6 tin Size PM Owner's Name _ r V�\__ '`!�'_�[-- --- AddressPhone 'I Conlydctor ill&I �'j,._Addresc ;� 'C F"License Nn�� ` �' Phone ( r ----- TYPE OF WELL/PUMP; NEW WELL (:7 WELL REPLACEMENT f", DESTRUCTION 17 PUMP INSTALLATION r, SYSTEM REPAIR ,>t OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �_._._ DISPOSAL FLD. PROP. LINE FOUNDATION _ AGRIC_ULTUBE WELL __ OTHER WELL---- PITSISUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _— I , Industrial CS Open Bottom 1..1 Manteca Dia. of Well Excavation_— Dia.of Weil Casing �i Y. Domestic/Private Cl Gravel Pack J;1 Tracy Type of Casing _-_— Specifications C Public 11 Other I I Delta Depth of Grout Seal .— Type of Grout hri�dtion ___ Appian. Depth I I Eastern Surf a Sadi Installed lair d i Repau Work Done K Type of Pump ! H.P. • State Work Don If Well Destruction {:I Well Diameter Sealing Material{top SO) ii Depth _ Filler Material$Below 50'1 1 TYPE: Of SEPTIC WORK, NEW INSTALLATION I I REPAIR rADOITION i i DESTRUCTION 1 1 IN*septic system parnutted it public sewer Is i { available within 200 feet.t i1 ! Instaflawn will serve: Residence— Commercial-- Other Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: ��_ Water table depth-- — i f SEPTIC TANK [I TypelMfg Capacity__ . No. Compartments —Y PKG. TREATMENT PLT,0 Method of Disposal Distance to nearest: Well foundation Property Line LEACHING LINE (-I No. 6 Length of linea —� Total Iength/size FILTER BED I:I Distance to nearest: Welt Foundation Property Lina _ SEEPAGE PITS i I Depth Size —_ � _wF_._ Number SUMPS t I Distance to nearest: Wail_— foundation .._--___.— Property Line r DsSPOSAL PONDS l I i I huruby certify that I have prepared this a kation and that the work wig be done In dccordance with San Joaquin cosi t :} P Pa pM� aq illy,ordinances,state taws. an It rules Arid reputations of the San Joaquin Local Health D3trict. Homo owner or licensed agent's signature certifies the loilowing: "I certify that in the performance of the work for which this portrait is 4sugld.I sw nr omptoy any parson in such manner as to become su that)to workman's COrnperlSallOn laws of California.”ConlraclOra hiring of Mr!}contraefis►g tagrtatta certifies the following:"i cavity that in the performanCa of the work for which this permit,s Issued,I shad empfoy pmaons subject to vvorktttan'e Gompons, 4 bun laws of California." f The appiican st c lot all required inspis a. pier rowing on revat" du. 4 [ ' / � 1 Signed X_— Title: _rl Data' FOR DEPARTMENT USE ONLY c Apphc;arion Accaptud by - ... _.�� —.— Date '`2 ,� At" t 4 { Pit ur Grout Inspection by Y– ()ate � Final inspection by !If t•ddil,bndi COrnmenlE'. S!k 4h6-67P1 [l Loai 3693621 L7 Manteca 8237104 0 Tracy 835-63M Ap,, wdn! Return all copies to: Environmental Heelm PefmitlServiceb 1601 E. Hstelton Ave., P.O. Bok 2009, Slk.,CA NMI � 13 V --- -----Y . 11 ,.hf0 AMouti1 JUE AMOUNT HEMITTED CCK RECEMB By DATE PERsIMI-1460. i4 f k 4 �`