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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/of install the work heroin descr,bm rh.s aopkicatan is made in compliance with San Joaquin County Ordinance No.5A9 for sewage or No. 1962 for well/pump and the Rules and Regulatwns of the San Joaquin Local Health Diis),trriCi��ct.. / �(` /I J s Address J�..il, 1 Y r 4+�1 r1 �'=•------ City �G.�'� t- Lot SirezC_._�?—V 1! PM Owner's Narr 77-- Addre s.,?yy1' .N �t>� ,�<i!�<21'�7Phone -- -- - - Contract14'4 tld f�plt.ee_ Address ` -_J�!_y�I _ License No—?29.?26 _ P`hone 3W---Vc'-1- TYPE Of WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION i ' PUMP INSTALLATION SYSTEM REPAIR OTHER i DISTANCE TO NEAREST: SEPTIC TANK . ... SEWER LINES __— . __ DISPOSAL Ft 7.—.�- PROP LINE FOUNDATION A:,AICULTURE WELL _ __ OTHER WEt L_—_ PITS/SUMPS _ INTENDED USF TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS '�dustr I Jpen Rottom i : Manteca Dia of Well Excavation______ Dur of Well Casmq _ Domestic/Prive e i Gravel Pack Tracy Type of Casing _- ____ Specdrea"ns Public ' Other Delta Depth of Grout Seal Type of Grout Irrigation --Approx Depth Eastern Surface Seal Installed by._-_—._ Repair Work Done Type of Pum;, HP -_ _ -- — State Work Done -- -_--_---Well Destruc!ron f. Well Diameter Sealir•Material(top 50'1 ._. __ _._ ------ Depth Fdler Material IP•ow 50'1 _._ _ ryPE OF 5FPiIC WORK: NEW INSTALLATION . REPAIR A DITION OEST.IUCTION (No"piic system permitted of pubbc sewer rs ✓ avarlabio within 200 feet l Installation will•eroe: Residence_— Commercial -__ Other Number of living units:-L Number o t)edr�oom/s G rte,t Character of s-A to a depth of 3 feet -_ t_z!`f1N"�_ .__—_ _ Water table depth SFPTIC TANK f I Type/Mfg -- _ -- -- _--- Capably- No. Compartments ----_-- ^ r. TREATMtNT PLT.I I Method of Disposal Distance to nearest Well ---. _.—_ Foundation----.- . Property Line - ----.-- -- --- LEACHING LINE IPP"No. A Length of lines pD__ Total lr g hisire FILTER BED t i Distance to nearest: Wen Foundation 1�_-_ Property Line SEEPAGE PITS I✓Depth tt�_—__._Sire 3�0.__-.-_—_ Number_yg_-_,�_ SUMPS i Distance M nearest: Well (� _ Foundation, lC Property line DISPOSAL PONDS I 1 hereby certify that I have preprred this application and that the work iii be done in accordance with San Joaquin county ordinances• state laws, and 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 work for which this porno is issued. I shall not employ,any person in such manner as to bw.ome subject to workman's compensation laws of California •Contractor's hiring or sutscontractrng signature certifies the following:-I certify that in the performance of the work for which this permit is issued,I shell employ persons subject to workman's compensa tion laws of California." The applicant must call for aLL aqu red inspections. Complete drawing on reverse side. --• aa: �_C) Signed X _ '1` - �—t ��_ Tr.le Date: _y�.-� _.. - J FOR DEPARTMENT USE ONLYa Application Accepte.l by -- _-- --- - - - -- Data ! h LAF� Aree Q - Pit or Grout Inspection by 1 X/ L Date--- -Final Inspection by ._ _ _...._ Date 1 Additional Comments — -- __ ---- --- — - —- -- ---- Stk 466-6781 :' Lodi 369.3621 II Manteca 823-7104 L)Tracy 8354M Applicant Ruturn all copies to- Environmental Health Permit/Services 1601 E. Haretton Ave., P.O. Box 2009, Stk.. CA 95201 FEE AMOUNT DIiE AMOUNT NEMITTED CASH RECEIVED BY DATE PERMIT NO