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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/or install the work herein described`. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weil/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address / _,� � � ,,, City x9,077Lot Size 4k PM Owner's Name Address a Phone - t ContractorLiieilse fVo._-f [?,1VlcJ Phone "TYPE OF WELL/PUMP: NEW WELL � WELC'RE'-PLACEMENT"7 A'j' k` DESTRUCTION ❑ --- RUMP-INSTALLA710N� SYSTEM REflAfR-p^�^^-• -- - + ! S OTHER"p DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ �_ DISPOSAL FLD. PROP. LINE 42f- I i FOUNDATION —��- AGRICULTURE WELL OTHER WELL PITS/SUMPS -h-5Z--)" INTENDED USE 'TYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIFICATION ❑ IndustrialH � ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ��,; Dia. of Well Casing A Domestic%Privattsr "Gravel Pack ❑ Tracy Type of Casing_- G Specifications b t x T �_. ❑ Publics [] Other ❑ Delta Depth of Grout Seal �-zr- Type of Grout it/ ❑ Irriga[o aS�a�pprox. Depth ❑ Eastern } Su ace Sea! Installed by Repair Work Done ❑ Type of Pump ,_ AVP. ��L � I State Work Done_ F Well Destruc ion 4jV0 Well Diameter Sealing Material -top 50 Depth Filler Material (Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet. W Installation wilE'serve-Reside cn e� Commercial_ Other Numberr of diving units Number`of bedrooms i I Chara'ter otf soil to a depth feet: �' Water table depth SEPTIC TANK�`'—Q Type/Mfg Capacity No. Compartments PKG. T �ATIAENT;PLT- ❑ ""i��rljsiltl �`' �. f Method of Disposal Distance to IWell Foundation-_ Property Line LEACHING LINE ❑ filo, & Length of-lihes �•t T Total length/size FILTER 9ED ! t ❑ Distan e-t"earest:- WeiI s ; -Foundation !Property Line - SEEPAGEPIIS ❑'�fbpth4 ize h�s �;� Number . �; SUMPS I I ///L��. ;stance to nearest:- WeiU>. Foundation Property Line DISPOSAL PONDS ❑ i� VVV hereby ' iz. certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations.,of the San Joaquiri2Vp al'•}iealth District- ` Home owner'of.11censW agent's signature certifies the'following: x� k employ an i'c' g '"I certify that in,the'performahce of the work for which this permit is issued, I shall not P Y y person in such manner as to•become subject to workman's com6ensation laws of California."Contractor's hiring or sub-contracting signature certifies the folloliving:I certify that in the performance of the work for which this ertr it is`•issued,I shall employ tion laws;of Ge ifotnia."" p P Y persons subject to workman's compensa- tion The applicant .f��' all re i c£w �Gomp bte drawl .g on re r ide. 5 rt Signed XI 1 /,>•,A ` It1e:-- Date: ! FOR;DERARTN USE ONLY Application Accepted kiy ` ; Date r f /�/ p \~i ti L // Area ^� ` Pit or Grout Inspection by Date 6,:� Z Final Inspection j!by Date Additional C L merits• 1 + tl t Cl 5tk- 4W- 67-81— 66 f781—❑ LLodi 3693621 _ Q Manteca 823 7104_._.es ❑ Tfacy;83x6385iI Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., .P.O. Box 2009r Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDCK:F INFO r CASH RECEIVED BY DATE PERMIT-N0. + EH 3-24 REV,vH5l EH -��- 14-28 _ l �l¢7�2- L