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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Tekphone (209) 466-6781 P."RMIT EXPIRES 1 YEAR FROM DATE (,.SUED (Complete in Triplicate) /.ap;icetwn is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein desrr:bed. this application is made in compliance with San Joaquin Coun•v Ordinance Nu.549 for aew4ge or No. 1862 for well/pump and the Rules end Reguut:orrs of thiiihan Jorquin Local Health District. Job Address �p� a �I• r` '"' City`L�re�_ Lot Size_ ��_ PM Owner's Name �' + ��I` Address L0�7 f v'�`" �-r U�� phOf1e p 7- (.:So Contractor Address _ _ License No. __.___—Phone F WELL/PUMP: NEIN WELL N REREPLACEMENT i-) DESTRUCTIO PUMP INSTALLATION SYSTE EPAIR ❑ OTHER Cl (STANCE TO NIEARE IC TANK 4-0 4- SEWER LINES _ 11SPOSAL FLD. _ PROP. UNE / FOUND I _ AGRICULTURE WEL D OTHtR-WELL �_ PITS/SUMPS --� — INTENDED US—E---,TYPE OF WELL P AREA CONSTRUCTION SPECIFICATION.; C Industrwl6Y 0 om Cl Manteca ia. of Well Excavation Dia��,octell Casing �lU Ovals O Gtrval Pack, �� Tracy Type o n Public 7 Otho f ', D`ilu��, Depth of Grout Sea� I -- T�iona -- -_--.. .- ypa Cl Irrigation �( . Depth (I Eastern -5tMWJ Coal Installed by Repair Work Done i I Type of Pump o t .Pjgbt c H.P. _ ��_ State Work Doaa Well Dasvuawn Well Dtarneter T� rig Material{top 50') Depth—��Q_--- _ Filler Matetfail$plow 50'1 ._--- _-_----- - -- --- _--- — TYPE OF SEPTIC WORK: NEW INSTALLATION HEFA.IH/ADDITION I i DtSTRUCTION 1 : (No Wpt c system permuted if public sewer is availablo within 200 feet.) Installation will serve: Resider;e_ Commercial _ OU,ar Number of bwng units: —I— Number of bedruoms Character of sod to a depth of 3 feet: _` -__ _. ..Wdtui table depth. PEPTIC TANK Type/Mfg -_. e,27'-44".f--Capacity.--IA - No. Compartments PKG. TREATMENT PLT. : : `` r t Method of Disposal Distance to nearest: Well�7_ — foundation —? Prupeny L,na --------y------- -- ^ LEACHING LINE No. &Length of lines [�Q. "' dU Total longthrsuo FILTE9 BED Distance to nearest 'Noll Foundation 101.__.-.__ Nupfirty Lela M SEEPAGE PITS Depth —Sue ---- -^^-�- — - _ Number---� - - SUMPS Distance to neere•a: Well Foundation1 / I P' Property Line DISPOSAL PONDS _ I hereby certrt; that I have prepared this applieat,an and that the work will be done in aeco(daneu with San Joaquin county ordinances, state laws, and rules and reguiations of the San Joaquin Local Health District. Home owner or licensed agent's signature cartrtie.s the following: "I cenity that in the performance of the work f)r which this permit is issued, I shall not employ any person in su.:n manner as to become subject to workman's compensation laws of California." Contractor's hiring ur subcontracting signature sonifies the following:"I certify that in the performance of the work for which this permit is issued,I stall empl„y personz,subject to wookman's eompensa uon laws of California rte applicant must call for all required mspecupo omplete drawing on reverse side. sig-led X '� J _ Tale ---�cn_7rif:—r -- Date: rOR ,)i0ARTMENT USE ONLY Application Accepted by `�� / Oats - -_� Area _ Pu or :,rout Inspucuon by ._ �.f"rEa�--_._ Data �'_._ Final In ction b i _�. —'��/'� dpe y I �t� --- --- Data� Ol r.dd conal Cunrments: — Stk 466 6731 Ladi 389.3621 Manteca 8237160 I 'Tracv 81 6385 Applicant Return all copies to. Environmental Health Parmn/Services 1601 E Hazelton Ave., P 0 H r. 2Cfi. SM., CA 95201 INFO,—EE AMDUrrt UUt _ AMOUNT REMITTED CA7ya�� RECEIVED BY I -- UATE_ PEAM11 NO L. _.4'et. �[/ l _ ; / ,/' / -� Y