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APPLICATION FOR PERMIT ' SAN JOAQU1N LOCAL HEALTH DISTRICT 1601,„E. HAZE::i ON AVE., STOCKTON, CA 1 `'.. `Telephone,{209) 466-6781 4 iPERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) This i Application is hereby made to the San Jo1aq�!Ordinance No.cal Health'District 49 for sewage or'No. 1862 for well//pump and he Rules and herein. Regulationnss of the San application Joaquin made in compliance with San Joaquin County f.. Local Health District. F c Aclac e s Job Address ►�� (Z0. City K. •- Lot Size' � PM MCI (A '4 J or=i►� C�11I1 roR�r� ,. Address �e�?7 A _QuMA y Owner's Name /a 7 M1 C'ARGlLe;.; Address ]0 {�VaV �� License No. ,2y�q�$ Phone Contractor - TYPE-OF WELL/PUMP: NEW.WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ . SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO.NEAREST- SEPTIC TANK', , SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION t' AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TY.PE'OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS Dia of Well Casing ❑ Industrial ❑.Open Bottom ❑ Manteca Dia. of Well Excavation❑ TracT Specifications of Casing El-Domestic/P,rivate C.Gravel Pack y ., Type g Type of Grout Q Public ❑ Other ❑,Delta Depth of Grout Seal I al + ❑ Irrigation zti �APProzr Depth. ❑ Eastern Surface Seal Installed by H:P State Work Done ;. Repair Wor one. ❑. Type of Pum -p r [” .. Sealing Material (top.,50') L� 4 ' Well Destruc ion ❑ Well Diameter 1. 1.X._ Depth a< Fiber Material (Below 50') �.. permitted o se TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION DESTRUCTION ❑ aNailableiwithine200 feet.) I if public sewer is InstaflationIwill serve: Residence Z Commercial ther i Number of edtooms �.W- Number of units:, Z Water table depth j Character of soil to a depth of 3 feet:. Capacity f6Qd �— No. Compartments t SEPTIC TA ❑ Type/Mfg ' = Method of Disposal a�PKG. TREATMENT PLT. ❑ Q6-1 +.=Foundafion Property Line Distance I:6'nearest: Well�� r LEACHING LINE ❑ No. & Length of lines Totallengthlsize i Well Foundation Property Line r FILTER'BED ❑ Distance to nearest; _ J - ! Number SEEPAGE PITS Depth Size - 4 Pro a Line= SUMPS ❑ Distance to;nearest: Well Foundation P rtY i. -, ,,,✓` DISPOSAL PONDS ❑ f 5 I hereby certify that 1 have prepared this=8pplication and that the work will be done in accordance with'San Joaquinco'unty ordinances, state laws, and rules and regulations of the'San Joaquin;Local Health.District. ' '. . Homeowner or licensed.agent'ssignature;certifies the following:--certify that in the performance of ills work for,which..this permit`is issued, I shall not employ anv person in suc4i mannert n he ai t6 &rfo8_90 A e t he work for whichthss tPerm t is.iss ed,I hal empl ty p6rrsonslsubje t t wo kmanring ls compensa- certifies the following: 'I certify _ P - PBS `A tion laws of..Califomia." tt R The applicant must for all req .ii 4 mspec ns.(Complete drawing on reverse side. 12 21 ! e 1 +� (/y�1��l r�- R ., Title: Date: Signed ..� .-_�w ..r �.,J i � -�. fi ;,• M F DEPARTMENT USE ONLY, n �j } }; Data �C `" - f,4rea v Application Accept, by, r ~ t "R`+_' -" '�` Date Final-Inspection by "` Da#e Pit or Grout Inspection by , Additional Comments: • —�fl St1c 466 6781 """ "❑'L'olii "369 3621''""" ❑`Manteca 823 7104 ❑'"teCY , Applicant- Return all.copies to: Environmental Health.Permit/Services 1601•E. Hazalton Ave.,-P.O. Box 2009, 5tk-, CA 95201 4.1 RECEIVED BY t GATE PERMIT'NO. FEE AMOUNT DUE AMOUNT REMITTED C '- INFO + EH1324(REV.I/B5! � / g�� EH 14-28