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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1.601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6783 PERMIT EXPIRES''I YEAR=FRUM'DATE ISUE[S ' s",..,• �^ ,; .,: . •... �, (Complete in Triplicate) Application is hereby made to the San J r:. ` It r 1 Joaquin Local Health District for"' 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 we and tfie Rtffas and Regulations,of the San Joaquin K Local Health Distnc�t, f-" _ t rr Job Address � O � {2© Lot Size w z ?M ...-. , , Owner's Name dl�/,_ Address- 00�� + "* ,� Phone. _ Contractor Address TYPE OF WELL/PU License No,__phone NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 -- , .- PUMP(NSTALLATiON ❑ SYSTEM REPAIR J-DISTANCE TO NIEAREST-.-SEPTIC TANK OTHER Q SEWER LINES , DISPOSAL FLD:, PROP, LINE. FOUNDATION__ AGRICULTURE WELL OTHER W" Eu INTENDED USE PlTS1SUMPS TYPE OF WELL PROBLEM AREA CONSTRUCTION-SPECIFICATIONS - 0 irrdvstrial ❑{)pen Bottom • ��;Manteca t �+. Q Domestic/Private '" '^'0n` '' -'' 3 �a of Well Exc,ygti°� Dia. of Well Casing ❑Gravel Pack p Tracy- Type of Casing ^# 0 Public- ❑Other O Delta Specifications ❑ irrigation t `ice f-J Depth of Gout Seal Type of Grout ---Apprux, Defth O Eastern! �Surface Sea(Installed by Repair Work Done t3 .Type of Pump H.P. State Work Dane ti`!at Destruction CI Well Diameter I. - -1. Seng'Material(top 50) . I; - Depth }" '} ��Filler Material(Bel Sp' }'r `t •^ l i TYPE OF SEPTIC yltipliK., NEW INSTALlAT10N d 11Epg111/14IIDiT10N11 DESIAUU11UN ❑ (N)septic tem P ys permitted:ffpVbff0 sewer,is Irrstaliaxlon will serve: Residence,�!� available':within 200 feet) t Commercial Other fi Nurtber of flying ukirts:� or of be ooms oz i Character of soil tD a depth of feet `K SEPTIC TANK p Tlg ' # -.-WaneMable depth f /1 1 PKG. 7ftEA'YkfENT PLT: r . . Capacity No. Comportments Method of Disposal A-kA.� r-XzJ Distance2o.nearest. Well. Foundation_ , Property Line yJ` LEACHiMG LINE t Ell g Length of fines_ �-- �'p � FILTER BED Total fen9thfsi d f Q Disiance to nearest: ;Well Foundation Property-}d i Line _ a 1' SEEPAGE PITS Cl pth. Depth• SUMPS Number ❑ Dist _Size ance to`nearest: t _Foundation DISROSAL PONDS 1] = _ _• Property`Line I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin cou r rules and regulation of the San Joaquin Loom Health District aq my ordinances,state laws, and Home owner or licensed agent`s signature cortifies the folbwing- "I certify that in the performance of the work for which this ploy any person in such.manner as to become subject to workmen's con permit is issued. I shall not � certifiesthe fallowrng"`l:certify;hat in the perf manca:,ofthe work for whfc�frrs perfnit Esq Ceadlif sha11 emConntractor's hiring or sub-contracting signature tion Ml of California." p Y persons subject to workman's compensa- The applicant rr}trst call for aB required inepectiprts; 00vnplete drawing on reverse side. Signed - $1,_ Tine: a= /�,47's ., --_ Dere: # s' F911 afFARTME�USEONLY Application Acceptrid by w Date Area 'Pit or Grout inspectkrn by _ F�ixaf lrtspection by Date Additional Comments: _ ❑Stk 46&M U Lodi 369-W13 AAanteca 823 7104 i Applicant-Return all cl?", to: Enuironmenbol Haeith Permit/Seri ION 1601E ze t rt A"— p. Box 2009 Stk.,CA 952Q7 y s r AnIIDUNT OCHE, AMOUNT REMITT D. k RECEIVED BY_ i * DATE PERlAIT"NO.' 3asal.troelr t�a si '� 11 _ _.. .. ._ ... � -. . ' t - - _ _ ..• �3 �" 4?��Gly"