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g pPPLICATIOWFOR.PERMIT SAN JOAQUIN LOCAL,HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1.YEAR FROM DATE,ISSUED (Complete in Triplicate) mance No.549 for sewage or No:,1862 for well pump and the Rules and Regulations of the San Joaquin Application is hereby made to the San JoaquinOrd cal Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Local Health District. r ,�( ° d J1 -,-?J PM /Trot Size ` la 85 '1 1� city Job Address one lR 1/�L��P S f f:Address Owner's Name 8 ��— Z s 1 t License -; Phone 3 �� Contractor's Name LLREPLACEMENT DESTRUCTION ❑ TYPE OF WELLIPUMP: _ N OTHER ❑ I SYSTEM}REPAIR 0 PU{�I1P'INsiAJ: AT10 y Esx. . DISPOSAL FLD a -PROP.-LINE= v (�. SEWER-LINES ,,�-- DISTANCE TO.NEAREST:rSEPTIC TANK, / r OTHER;WELLF � PITS/SUMPS I� tr LJV FOUNDATION AGRICULTURE WELL; TYPE OF WELL PROBLEM AREA i CONSTRUCTJQN'SPECIFICATIO S INTENDED USE t/ Dia. of Well Casing Open Bottom ❑ Manteca Ola'of Well Excavation .• ❑ industrial t Specifications �, � �_ y Type of Casind -r� Type of Grout. omestic/Private. ❑ Gravel Pack ❑ Trac l " ❑ Delta f -Depth of Grout Seal. ❑ Public ❑ Other ace Seal installed byA + �pprox. Depth ❑ Easter j ,- ❑ Irrigation State.Work Done t Repair Work Done ❑ Type of Pump tSealing Material Stop 50'1 i Well Destruction ❑ Well Diameter �-- 1'�-. ,_{ Depth Filler Material (Below 501 is j available within 200 feet.) TYPE OF SEPTIC WORK: NEW.iNSTALLATION ❑ REPAiR/ADDIS N ❑ 'DESTRUC1kON ❑ [No septic system permitted if public sewer Commercial Other{ �� >- installation will serve: Residence r .Number of bedrooms ..Number of living units: �u a I _�"' ;"+VVae�tattle depth Character of soil to a depth of 3 feet: ,, - N ,Compartments Capacity/ *+ ,;�. ❑ Type/Mfg Metrjod of Disposal `' -SEPTIC-TANK " s PKG TRE4TMENT`PLJ. ❑ r ✓� `' "' ` rt Line We11 F.0/mation Prope y:y ^i` s Distance Acr nearest: ,.. "Tota1'lengtli/s ze J LEACHING LINE +❑ 'No• & Length of lines :�: Property Line I +`Foundation , * ` FiLTER BED ❑~'Distance to nearest: -Well a i i ti Number ` i ❑ Depth Size T Line — SEEPAGE Pas "� paundation'' Property. SUMPS ❑ D•+stance'to nearast "� +. .� t - DISPOSAL PONDS ❑• `.. application an0that the work will be done in accordance with San oa�quin county ordinances, state laws, and 1 hereby certify that l'have prepared,thls app s:= f ..6 \' l certify that`in the performance of the work far which this permit is issued,.1.sh11 all'not :3 rules and regulations of the San Joaquin Local Health District. ✓ itre t ,. Home owner or licensed agent's signature certifies the following: " :. e employ any person in such manner as to become subject to workman s cbmpe^cation laws of Californias"`Contractor s hiring or suac?i^g sig^a Y. N cmplo s the following:"I certify that in the performanc'`of e•worrk for which this permit is issued,1 shall erimploY puns subject to wo�rkrrlan's co pen�se tion laws of California." /(caSall for all specti pete drawing on reverse side. / -The appDate: ill 0 } ttle: 7__ R Signed FOR DEPARTMENT USE ONLY , +^ Date Area , .. Application Accepted by .,.1 G� Date Pit or Grout Inspection by Date Final inspection by _ Irl 1 Additional Comments: odi 369 3GL1 ❑ Manteca 823-7104 ❑ Tracy 835 63 its+D Stk 466-6781 { Applicant Return all copies to: Environmental Health PermitlServices 1601 E. Hazelton Ave., P.O. Box 2009. Stk., CA 95201 y;a' CK RECEIVED BY DATE f PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CASH 4i INFO + EH 1324(REV.10!83! '- EH W28 4 \ ..... 1.� •, .-.. i `u. .., --