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APPLICATION FOR PERMIT SAN JOAQLIIN LOCAL HEALTH DISTRICT 1601 E. HAZEi ON AVE., STOCKTON, CA Telephotie 1209) 466-8781 > PERMIT EXPIRES T 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.649 for sewage or No. 18£x2 for welllpumta and the Rules end Regulations of the San Joaquin Local Health District. ' City Gt^�J —_ Lot Size �." �_ PM ._. Job Address _� ,....� r�� -�l+!Y. _. Owner's Name _. ... t.Ld{ _. Address - � _-- Phone J �J Contractor Address `'�... � License No.��S £'hone��9��_. ' } TYPE OF WELLIP"JI?: NEW`WELL C— WELL REPLACEMENT I.J DESTRUCTION ❑ PUMP INSTALNZI� N C (-SYS-"fiVI-REPAIRS�`�`'`'i OTHER Ll { t DISTANCE TO NEALEST: SEPTIC TANK �.__� < SEWER LINES .._ __,._......._ _ DISPOSAL FLD.._�. PROP, LINE .... — } _. ._FOUNDATION _j___ \U�. �RICULTt�RE WELL _.,.., ....- OTHIPA WELL.�,_.._ _ PITSI�SUMPS _ r INTEINDED t/SE TYPE OF WELLI PR08L ENI AREA CONSTRUCTION SPEL�ONS LJ industrial �. C Open Bottom M Manteca�`� Ora.of Well Excavation___ t Dia.of Well Casing lW Domestic/Private f 17 Gravel Park i Tracy `\ ype.af_,Capllq .-.......1.__ Spec+ficatiar7s Public i (7 other C; Delta \Depth of itout Seat .,.. -" .-_. Type of I I Irtglation #A 10, _.......__Approx. Dep h.- I 1 Eastern Suchen Saul Installed try. —_— t ,l � tri _. Repair Work Bona [„r Type of Pump _J _✓.._._._._ H. State Work bone y t t t 1 Weal Destruction 1❑ Well Diameter �_ Sealing Matenil Itop�i7'f _ _.... k }• Depth Piller Material TYPE OF SEPTIC WORK: NEW INSTALLAMON 1 !--*"-AIR 4ADDI1 ION DESTRUCTION l ) IN'o septic system parmifted if-public sewer is-- i available within 200 feet)`) Instattation will servje: Residence fa Cmercial Other, - ! t Number of living units: ,- ,.j_„�)NumbLf of Dorris 3i !� f A Character of soil tb�'a tlttpth of 3 feet:---!5._ _— f.__ __,,��•�_ -"Wale( table depth V.. `p..._ �. t SEPTIC TANK 11> Typel(Llfg \\ ! _t3iLNo. Campartmertxs 2— PKG, TREATMENT PLT. C. Method of Disposal _. _._ ... t } .... Distance to near 2: Well t Ft>ur+datian..� _ .....__ Property Line , Wi \ �� `�7`' Total ion thl�sixa r LEACHING LINE <ift'Mo, 8 Length of lines _ 1.,.._w g FILTER BED` Cl Distance to nearest: Well_yr�sl! Foundation / Property _. _._.. __ I 1 SEEPAGE PITS W Depth .� ._Size_ .._ �� Number .._. _ i SUMPS1 # Ll Distance to ncarew. t Well t._._. Foundation ,, Property Line DISPOSAL PONDS CI i 7-1 I hereby ceriify that i have prepared this applicaboA and that the work will be done in accordance with San Joaquin county tfrdinances, state laws, anti rules and regulations of the San Joaquin_1ocal Health OiSbict. 6 I Home orWne(or licensed agent's signaturerVnifies the following: "I certify that in the performance of the work for which this`.�ermit is issued, i shall not employ Iny parson in such manner as to becor' S''ubiect to warkman's compensation taws of California.”Contractor's hiring&sub contracting signature certifies the foaowinj�-1 certify't4aY in:ttrb prirformahce of the work for which this permit is issued,I shalt employ persons subie�t to workman:s compensa- tion Iaw1 of California"� r t The appiican must Allfor ail-rg ad i^-. ctionel Compote drawing on ravorse s'sde. i _ Signed;k___, _.... . .�... Title: FOR DEPARTMENT USE ONLY Applicat}ion Accepted by _ y �s~�� Date _ Area tEt or Grout Inspection by ��-/,_._ a e .' J final Inspection by 14 + � Datee1jrr' Additional Comments ` ❑ Stk 466-6181 L r 369.3621 4J1 Msntere K3�ldd~I71- 1 rJ Trecjj' 36 ta385 o d,.-•V21, 4-Ke Applicant - Return all copies to: Environmental Health PermitlServices 1 i0l;F. Haxaiton Ave., P.O. Box 2W9, Sit CoA t a r _,FEE AMOUNT DUE AMOUNT,REMITTED C K H RECEIVED BY DATE PERMIT' N�yO.�) .. 1111 ta-26 IRtY.I,ti 5l / /1 .J v r�/'6�� O{7LJ i•,/ �> EH ti•7+6 ! (f