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APPLICATION"'--OR PHIMIT SAN JOAQUIN LCAL}IEALTH DISTRICT • u 1601 E. HAZELTOWAVE.,,1 STOCKTON, Cly.-,,. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE (Complete in Tr,�'Ilpllcate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install&.Work herein described:This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump enditipjN�e4,and R.epulations of the San Joaquin Local Health District. ^z (� Job Address '*� LJ-400-()� V-1 CSA 14� CC City >y k+r n PM .l^ _—p• c� - ••.� r'T'"i��. :yiy�F~/ � `may Owner's Name h� _ Address 1 l� PA,1 Contractor's Name ��//��/��y l2 Ali.. _ — v2 -r-iLi C��rtC�icense No. •�� (� �y r: PhonQ . . TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT I& {�ESTRUCfiIOM ' ;1` PUMP INSTALLATION ❑ SYSTEM REPAIR X DISTANCE TO NEAREST: SEPTIC TANK to SEWER LINES` DISPOSIAL FLJ� ? RQ� LINE FOUNDATION - AGRICULTURE WELL OTHER VLL` _ PITS/SU,M1i)RS ,T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO ;. t ❑ Industrial - --�-❑-OpehBottom ❑ Manteca Dia. of Well Excav n 7 -Dia of., acing' ❑ Domestic/Private :?I;Graval Pack ❑ Tracy Type of Casing G Specifioait4na ,Public ❑ Other ❑ Delta Depth of Grout Seal - �.:rf" `.'`,.''.Y fe tii`Gout'. El .Irrigation ' A' prox. Depth ❑ Eastern Surface Seal Installed by G- rt L Repair Work Done Pd Type of Pump ',54L.94-, H.P. - State Work Doriey�� r��n•(�}A*C��f✓ Well Destruction Well Diameter �_� Sealing Material (top 50') 1-109 mr e't., Depth Z Filler Material(Below 50') •ler-- - .A.1 i�l TYPE OF SEPTIC WORK: ' NEW,INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No s8p"fic'system permitted if public sewer is available'W)t in 200 feet:)=' Installation will serve: Residence_ Commercial_ Other '.;. F.�._ . ?� •. ' Number of living units: Number of bedrooms = ' Character of soil,to a depth of 3 feet: _ -" ^ ' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No' Compartments f PKG. TREATMENT PLT.❑ Method of Disposal Distance to nea Well Foundation Property.Line. LEACHING LINE ❑ Length of lines Total length/size.. ' t' FILTER BED Distance to nearest: Well =--+Foundation— Property Lina- = SEEPAGE PITS ❑ Depth Size Number' SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with S2n;Jo, uin'coun pp eq` ty':ordinanpes,state laws, and a s: ..X ,. rules and regulations of the San Joaquin Local Health District. ;�'+ Home owner or licensed-agent's signature certifies the following: "I certify that in the performance of the y+orl�`f which t{liq permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contrdctars hiri qp`r;.Ub cor)trecting signature certifies the following: -1 certify that in the peHornlence of the work for which this permit is issued,I shall employ persons subject'to work s compensa- tion laws of California." 'K The appli ust ca for all required i ttis,. Coto drawing on arse side.Signed f Title: �e 4 D te" / oa ' . IV 4 C ,�rr li FOR DEPARTMENT USE ONL, SS ell Application Accepted by Date Pit or Gro. Inspection by Date �� Final Inspection by - -,Date .7 Additional Comments: ' r, ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 83x6385 r*� i Applicant- Return all copies to: Environmental Health Perrnit/Services 1601 E. Hazelton Ave P q Qox ,��tk,CA 9sFEE ;Gt)1 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY .DATE PERM.IT`N0. ♦EH 13-24(REV.10/83) � W EH 14-26 • ':a ',N'