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APPLICATION FOR PERMIT :IAN JOAQUIN LOCAL. HEALTH DISTRICT u' 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Completf; in ?rplicatel I or install the vio, Appiication is com lienee with San e San Joaquin L Joaquin County Ordnance No.Districtocal Health 49 for sev,age or permit 1862 for well/Jpump and the Ru es and tRegulatio d.o the Sanhis t Joaquin ` �. . made t P Local Health Disbict. t [/ City dA-- Lut Size �d 1 PM n LpaA>It �2 Job Address •- / Phone �X�1 Address dam: Owner's Name - Wr Phone Contractor—�+-L6 Address_.___lf��-�-- z --_. WELL REPLACEttENT DESTRUCTION u TYPE OF WELL/PUMP: NEW WELL OTHER PUMP INSTALLATION SYSTEM REPAIR ;_. _ SEWER LINES -- DISPOSAL FLS. PROP.LINE DISTANCE TO NEAREST: SEPTIC TANK - OTHER WELL_- PITS/SUMPS T FOUNDATION AGRICULTURE WELL -_---- V . INTENDED USE TYPF OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS- - Open$ottum i Manteca Dia.of Well Excavation_____.---- Dia.of Well Casing - �- C Industrial Type of Casing—. Specifcatio s '�Gravel Park =Tracy ----- C.Domestic/Private Depth of Grout Seal _ Typc of Grouter-- Cther L: Detra - G Public Surface Sea!Installs:by L: Irrigation _---- + _ Approx. Depth Eastern State Work uk.ne H.P._------------- Repair Work Done C Type of Pumf --- Well Diameter _. Sealing Material(top 50') Well Destruction _- --- c Depth_---- Filler Material(Below 50'1 --- -. available within 2w ice:r t; T'fPE OF SEPI'/.t+�,K: NEVJ INSTALLATION REPAIR/ADD'TION DESTFUCTION (No septic system oelt:,. +.:J it public sower is 9 ' -----.-_----- q' lnstaGation wdi sante: Rec-idence Y/ Other_ Commercial— Number of living units:4 Number of bedrooms ----Water tatlo depth Character of soil to a depth of 3 feet: ------- / , No.Compartments Type/Mfg Method of Disposal " g - Capaci:y_.r�.C�--- SEPTIC TANK - _ PKG.TREATMENT PLT. Foundation - Pljperty Line i Distance to nearest: Welliii`��+++�� - F _- Total length/size_ LEACHING LINE No &Length of lines _-�--SFT - nom 7- property Line. /'�/ ,07 Distance to nearest: Well_ �--. Foundation FILTER BED - _Size _--- Number SEEPAGE PITS _ Depth . Foundation Property Line - , SUMPS Distance to nearest: Well _-_- DISPOSAL PONDS state laws,and I hereby certify that I have prepared this application and that the-work will be done in accordance with San Joaquin county ordinances, rules and regulations of the San Joaquin Local H alth District. that in the work Home owner or licensed asuctfl�ns ergas:n-e cenities the become subjecs p6tryfi t wtor{man's.roympen anon Iperformance of Cafiforniare Contractor's hiring ri ch g orr sub t.^n't act ng signature employ any person certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ Persons subject to wo L ma i s compensa- r tion laws of California." applicant must :alt for all r ire pections.Complete dravnnp on reverse side. The Date: i Signed X--- Title: 1`� FOR DEPARTMENT USE ONLY - k /(� Date _ {2- - Area —-�C�— / -- - ..-_ Application Accepted by Date -J//A- _ Final inspect-on by-_ _L.2�'�. Pit or Grote Inspection by ---" i•"'- `- -_-- --- Addihu.al Comments: _ a serene 823-7104 -- Tracv 635 '6335 Stk 466 6781 _, L:v i 36..-3f•21 Applicant - Return au coFies to: Environmental ea h Permit;Services 1601 Hazelton.Ave,. P.O. Box 2009. Stk., CA 95201 s` - C; = D 8Y F�I)�ATE. PERMIT FEE �4MOUNT DUE AMOJNT REMITTED -OpSt{ �- _ RECEwE INFO _1 I - -------�- ;. .EH 13 24 IRC'r � . EN 14 26