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_U4 h Aw APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 46rn-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complete in Triplicate; plication is hereby made to the San Ju^ruin Loral Haab,District for a permit to construct and/or install the wort herein desenbed.This epplfcation is Ido in complianrn with San Joaquin Courty Ordinance Vo.549 for sewage or No.,1862 for well/pump and the Rules and Regulatiom of the San Joaquin call Health District. b Address __--- 3Q * lUO;_% City Lot si:n 11-2 PM vner's Name fi D.p. Address _ Phone xtl+actor �.�, rliLG a'2 Address.__d�_. /x7.1�.License No.� _Phone / 'PE OF WELL/PUMP: NEW WELL F1 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION L1. SYSTEM REPAIR ❑ OTHER ❑ 1 STANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LiNE I FOIjMDATION _ _ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Industrial ❑Open Bottom Cl Manteca Dia.of Well Excavation, Die.of Well Casing w ` Domestic/Private 0 Gravel Park 1-1 Tracy Type of Casing Specifications �] Public 1:1 Other rl Delta Depth of Grout Seal Type of Grout Irrigation ---Approx. Depth 17l Eastern Surface Seat Installed by _ (pair Work Done CI Type of Pump H.P. State Work Done_ O all Destruction ❑ Wolf Diameter _ Seating Material flop 50'i Depth Filler Material(Below 501 'PE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I.,) DESTRUCTION 1.1 (No septic system permitted H public-sewer is available within 2W'fect.1 Installation will serve: ResidenceCornmarciel Other Number if living units:4— Number of bedrooms __ 'I- Character of soil to a depth of 3 feet: _ �Lr'R_ '�- �J��,��(�i Water,table depth !0 :PTIC TANK 0 Type/Mfg !L'__. Capsctty—(!/' No, Companmenfs CG'.TREATMENT PLT.L7 - F - Method of Disposal Distance'to nearest: 1Vell ..J!c _ Foundation 1 Property Line_A ' ;ACHING LINE — No.1f lAn hof Imes ' Total length/size LTER .` BED 1"f Distance to naarast: Wr.II"./"f'7_Foundation_JO�T Property Line i EPAGE PITS 11 Depth "_.� $ize ,.._." _ _. � Number _ JMPS 1-1 Distance to nearest: Kell Foundation Property Line ; SPOSAL PONDS I"7 mreby certify that I have prepared this appliattion and that the work will be done in accordance with San Joaquin county ordinances,state laws,and les and regulations of the San Joaquin Local Health Dinlrict. 3mo owner or licensed agent's signature cenifies the lollowing: "I tenify that in the performance of the work for which this permit is issued,1&I not nploy any person in such manner as to become subject to workman's compensation lawn of California."Contractor's hiring or sub-contracting signature inifies the following:"I tenify that in the performance of the work for which this permit is issued,1 shall amploy parsons subject to workman's eompensa- ;n laws o1 Califomis." "applicant must cell for atl u' inspections. Complete drawing on reverse side. � gned x �mm_ _ Title: _ date:'_, 2— 2!e-1I FOR DEPARTMENT USE ONLY ypfication Accepted by Date Area tf _ 1 Lr I or Grout Inspection by ---- ----_�_� Date _ _,__. _ Final Inspection by e iJ` i. °�� Date is-k Z-� lditionel Comments: 4BS scv_, Stk 446.8781 L--Lodi 369-3821 �f`Manla'ccri 1-71Gd� �JTrsci 835Fi386 1�(-ko+�Lr COYi�ts1J �- (�% >plicant - R.-turn all copies to: Environmental Health Pormi:tServices 1601 E<5 HazaROn Ave., P.O. Box 2009, Stk., CA 96201 FEE AMOUNT DUE AMOUNT r ITTEt? CK a RECEIVED BY DATE PERMIT NO. ' INFO _ r:ASH