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APPLICATION,FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E:,HAZEL T ON AVE., STOCKTON, CA Telephone [2091 466-6781 i PERMIT EXPIRES i YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local HealthrDistrict fora ' made in compliance with San Joaquin County Ordinance No.549 for sewage or No. ] , permit to construct and/or install the work herein described.'7 Local Health District: "' � 862 for Msa . . well/pump application p m and p on is p the Rules and Regulations of the San Joaquin Job Address 2624 E. HARDING WAY " 1 Li ' STOCKTON ' #� city 60x11.5 - Lot Size PM Owner's Name GENE & SHIRLEYrARNAIZ P.O. BOX 8904 -STKN. , 95208 --_---- Address ARNAI,Z CONST. 'CO. , I Phone Contractor p.0. box 9334 STKN. , 9 TYPE OF WELL/PUMP: tlress _W"Pse 465-7054 NEW WELL ❑ e se Na.�_�Phone } p. �" ` PUMO-iNSTALL'ATION ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ DiST.ANCE.TO NEAREST�,SEPTIC TANK SYSTEM REPAIR ❑ OTHER ❑ FOUNDATION ~~ SEWER LINES ��!_ DISPOSAL FLD. PROP. LiNE AGRICULTURE WELL C--, OTHER WELL_ INTENDED USE `TYPE OF WELL PR06LEM AREA"CONSTRIJCTlON SPECIFICATIONS PiTS/SUMPS ❑ lndusiria! q Open Bottom ~� ❑ Domestic/Private v ❑ Manteca Dia. of Well Excavation. ❑ Gravel Pack ❑'Tracy I Dia. of Well Casing ❑ Public ❑ Other ".. Type of Casing l ❑'Delta Depth of Grout Sea! Specifications ❑ irrigation --Approx. Depth EJ Eastern Surface Seal Installed by a Type of Grout Repair Work Done Cl Type of Pump �� ' Wei! Destruction H.P. ❑ Well Diameter State Work Done ' Sealing Material (top 50' + Depth TYPE OF SEPTIC WORK: Material i NEW INSTALLATION ❑ REPAIIR/ADDITION ller Bel DESTRUCTION [No eptic system permitted if public sewer is Installation will serve: ResidenceCommercial k+ d � able within Othe N et.) Number of living units: i,< �t � Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/mfg --�l.P" - Water table depth PKG. TREATMENT PLT. ❑ n Capacity� No.Comparimenis " � t Distance to nearest: well r Method of Disposal Foundation Property Line�� r j ` LEACHING LINE ❑F No'& Length of lines 1. { FILTER BED CJ_Distance to nearest: � Well � Total length/sizer < Foundation_ Property SEEPAGE PITS 0 Depth t SUMPS Distaw " Size Number ❑ nce to'nearest: # Welly, DISPOSAL PONDS Foundation Property Line Alt t ❑ - r a I hereby 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 Joaquin Local Health District. Home owner or licensed agent's signature certifies the followingI wor employ any person in such manner as to ome",subject to woman's compensation hews of performanceof Contractor'skf r which t i permit is sub-contracting issued, Isignaltu�e certifies the following: "I certify that in rformance of the work for which this permit is issued, I shalt employ tion laws of p y persons subject to workman's compensa- The applican ust all for all r inspections. Complete drawing on reverse side. , Si ned x VICE-PRESIDENT Title: Date: 'DEC. 3, 19$5 FOR DEPARTME USE ONLY Application CalifAcc by Date gree Cd Pit or Grout Inspection y '�� "" 'r "•,.». .� -A .. r..,,�:_ , i Date Final inspection by ©1( �1Q� Ad 'Tonal Comments: ,- - - � •0 t Stk 466-676] Lodi 3693621 Manteca A A Iicant - Return all copies to; Environmental Hea th Permit/Servi es 7601,E.❑Hazelt n Ave.,93 P.O. Bo 20W, Stk. CA-9w O� FEE AMOUNT DUE- AMOUNT INFO RECEIVED BY y t EN 13-2441EV.iiws7 .^.^ k �,- +�«}•a '•f" `s �r �.J+� ' DATE PERMIT'NO, 3 t EH 14-28 �.©