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fl APPLICATION FOR PERMIT s SAN JOAQUiN LOCAL HEALTH DISTRICT , 1 E. HA AVE. STOCKTON CA 160 ' TCN 2E� � Telephorle..(.209) 466.8781 y PERMIT EXPIRES i YEAR FROM DATE ISSUED i (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 descrihed. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No, 1862 for wellipump and the Rules and Regulations of the San Joaquin Local Health District. Job Address " M O LOV,ed �aCI_4^Skljpd. City G Lot Size PM 0wner's Name +Q . �� Address _LPQ We • �u 6d Phone !(oO contractor.obt, Address 3233 License No C `�S'� rS Phone /�' ��9Z'76 i. TYPE OF WELL/PUMP: NEW WELL (ja WELL REPLACEMENT v DESTRUCTION Ll i'J4,,/3 PUMP INSTALLATION ri SYSTEM REPAIR C3 OTHER ®Sclj( 3zr1w DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES DISPOSAL PLO. POOP. LINE FOUNDATION ,�„^ AGRICVLTUAE WELL _ OTHER WELL. PITS/SUMPS INTENDED USE TYPE OF WELL: ._ PROBLEM AREA CONSTAUCTIO_N SPECIFICATIONS �r O Industrial ❑ Open Bottom CI Manteca Die. of Weil Excavation IQ Dia. of Well Casing f! Domestic/Private G Gravel Packff� Il Tracy Type of Casibg PVA Specifications I'i Public 1"iri OtherlYla.:ts+ti`++} I 1 Delta Depth of Grout Sealy S"�� Type of Grout r . I I litigation !j ApproX. Dopth I I Eastern Surface Sakti Installed by Repair Werk Done L] Type of Pump __ H.P. ._.., ... State Work Done . 3 Ir►� @ `�S Q4Gl. Well Destruction 0 Well diameter Scaling Material (top 501 _ . S 40 30 ` ac: Depth_,. l Filler Material leeiow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I 4.11AIR,ADD1710N i I DESTRUCTION i l INo septic system permitted if public sower is available within 200 feet.) Installation will serve: Residence_ Commercial__ Ocher Number of living units: Number of bedrooms Character of &oil to a depth of 3 feet: ,_ Water table depth! SEPTIC TANK Gt Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT, C7 I Method of Disposal Distance to nearest: Well .. Foundation. Property line LEACHING LINE rl N0. S L'englh of tines Total length/size I FILTER BED U Distance to nearest: Well _.. Foundation Property Line — I i SEEPAGE PITS I I Depth! , Sire ___ Number SUMPS LI Distance to nearest: Well_. Foundation_ Property Line DISPOSAL PONDS L"} I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin courtly ordinances, state laws, and rules and regulations of the San Joscuin Local Health District. Home owner or licensed agent's signature certifies the(allowing: "1 certify that in the performance of the work for which this permit is issued, I shall notIN employ any person in such manner as to become subject to workman's compensation laws of California," Contractors hiring or sub-contracting signature certifies the fopowing: "i Cer[tfy that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compansa- tion laws of California." The applicant must cap Lot all re aired inspections. Complete drawing on reverse side. Signed x ,- Title: Data. FOR DEPARTMENT USE ONLY Application Accepted bye! Dat _ A , G - �rG j Pit r Gro Inspection by ata Final Inspection by Date I Additional Comments: Q Stk 4813-6781 ❑ Lodi 359.3621 Q Manteca SM-7104 ❑ Tracy 835.6385 Applicant- Return all copies to: Environmental Heakh Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i INFOFEE AMOUNT CUE AMOUNT REMITTED CASH iReC'VVED ay DATE PERMIT'NO. . £H 73.2+(REV,k t m s+ J EM 74.28