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APPI.,MATION-FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA Te1epllar�e (209) L/�9--,? 2 D - _ '41PERMIT EXPIRES TYEAR FROM DATE ISSUED ACamplete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described. This application is Fmade in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1562 for well/pump and the Rules and Regulations of tho San Joaquin Local Wealth District. i; ! , ..." Mom� r[U E — Cii TDG "t F11�'"Lai Size C 2E a .. Joh Address .-_.:.___..�- T■ - Y�.:.�. �� _� fi/1 Owner's Name _ )��` !" Address 72-73 -5, /"ELSO/�//�. J/U� �D� phone Conlractor ,L�� -� � Address�� i c e n s e No,"!j�73t Pher,e zr TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C3 DESTRUCTION 0 PUMP iNSTALL.ATION ❑ SYSTEM REPAIR 0 OTHER M DISTANCE TO-.NEAREST: SEPTIC TANK -_ SEWER LINES - _ DISPOSAL FLO.- PROP. LINE FOUNDATION _ - —__ AGRICULTURE WELL. _ __ _OTHER WELL--------- PITS/SUMPS-==^ INTENDED USE" IITYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ---- M . 0 Industrial " . -r-� © Open Bottom 0 Manteca Dia. of Well Excavation—_—_----._..-_. Dia. of Well Casing -"---.---� n Domestic/Private `�,E] Gravel Pack Ci Trac Type of Casing_-- S vcificalion_, -. TM Y ------------ p •.. I'1 Public ;r Other 1-.-i Delta Depth of Grout Seal __..._..-_ __. Ty}�e of Grant_..____ I I Irrigation ,'Approx.;Depth I i Eastern Surface Seal Installad Repair Work Done 0 Type of Pump _ H.P, — --_ State Work Done Well Destruction •E3 Well Diamete Sealing Materiul atop 501 -. Depth ---- Filler Material (Seluw 501 TYPE OF SEPTIC WORT(:: NEW INSTALLA"T"ION)K_HEPAIR/ADDITION i i OESTRUCTION I t (No sepiir, system permitted if piiblir- sower iw °f available v.ithin 2W leet.l Q r ` Installation will serve:_Residence", Commercial_ Other { r Number of living units: °"-J_� Number of bedrooms Character of sok to a depth of 3 feet: LA ----- � -Water table riepth—_��__�x__—�_ SEPTIC TANK. w_ .. Type/Mfg (!0X Cgq'L'E Capacity C��D IrsfkL No. Compartments w_ Z___.-_..---•.--.---- PKG. TREATMENT PLT- ❑ r Meihod,6f isposa� distance tn'nearest: " Well. !_�_:J - Foundation_�d _ Property Line �Z� Tii LEACHING LINENo. & Length of lines Z "�-INE _• I°J � 9. � �---" l�ottaT length/sire_ I"ILTER BED i `'D -Distance to nearest: Welt f l J Foundation 2)1 -_.. Property Line _------ ~ - _ SEEPAGE PITS De th -2- FT, Size N 2— Depth.-2-5 - - _ �_--- Nurrrber 'SUMPS " Ll Distance to'nearest: Weg Foundation— 6 Property Line -•— �� _ � DISPOSAL PONOS f ❑ 3 hereby certify that I have prepared this application and that the work will he done in accordance Witt} San Joaquin county ordinances, state laws, 2md rules and regulations of the San Joaquin Local Health Drstrirt. Home owner or licensed agent's signature certifies the following: ",I certify that in the performance of the work for which this permit is issrled, I sf,a4 no?. irnploy any person in such manner as to become subject to workman's compensation laws of California." Ccntractor`s hiring as sufa-G ntractinq.s;pnaturea c6rtifies the following: "I certify that in the performance of the work for which this permit is issued, I shatl employ persons:iibjo(,T to wg)rkrnan'�--,t:arr Ixsnya tion laws of:io liforn . tl. The applicana I for i dins I, pe s. Complete drawing on freverse�sijd�e. Q Signet)X — -----Y Title: _ YY� / /�/z�-rT/14667 _ � _Weil - DEPr°Af3T'MENT USF: ONLY + Application Accepted by - -— -_ M Data �` _ tea- --_-•-•--- n Pit or Grout Inspection by —_ l7atm _ Fir�el Inspecaion hp _..... _._ _ Crag -- ` Additional Comments: _ __— 0 Stk" 466-6781.E ,-• CJ Lodi 369-3q1�� Manteca e223-7'�4" r 0 Tracy 83E,0099 l Applicant - Return ell copies to: Environmental Health Permit/Servires 16M E. Hazelton Avm., P.O. Box 2009, Silt, CA 95,201 FEE INFO AMOUNT DUE AM4UA41'Ri 1W17>,p C CASHt"E•CEIVED BY_ DATE PERMIT,NO, , " --- M -