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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL'FIEALTH DISTRICT Y 1601'E._HAZELTON-A11E.3_STOCKTON, CA s Telephone (f�146¢¢781 r .vJ l J? T;n,4 )TM 1O Ot t£•t4TSsn abso1 10 2tmNI12 to f PERMIT EXPIRES-1,YEAR FROM DATE IL .Y lago,q grit p snitlLtC .S .2DIJSq 2s A0u28S8T6 bs1evO0 QnitlU�Ov:i ..=syu:o:c•-(Complete in Triplicate) '''°o2"10141D'IxtF z9nillt:O bsnoiensmiG hAlo 4 tan: PVnt.{yvjy;-• r, Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work harem death- ed *.66 a _ .f• l�oication is made in`compfiancI"ith Sen Joaquin C,ounn Otdmance`No-549 for a Wage or No.1882 for well/pump and the Rules and A "'"borr of qhs San•Joaqu n Local Health Di grl ^Z 3 �;'�KF/�1.�'t+y�riL(�: 1 0 ynS 10 ,.li�i!2y e IbdOrZi`1 egi,,,Yy2 io flour}qx3 C980-C-lq �fTY,gbSq 9ril no Jset Oc'Vp&/y'ibsi niritiw aliew i9ma No ,t, oo_I c Job Address n M,icityoa r:n mKtPvo I:ot Si{`zafh At,gi•raa lr, nn;PM / __/ -J�- --- /} Owner's Name _�jtt-= Address-_ !_ .f fI'_"f'. �-- - - Phone � �Ip -- ' - - k _Jqs --- ?- --, -- r--- - j - -Contractor-.-. . __._� Address�._. 330 —(License No. Phone ' TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ / / \J PUMP INSTALLATION CI SYSTEM REPAIR OTHER DISTANCE TO NEARESTSEPTIC Pelf(®�� W1*�/� -- J TANK SEWER LINES DISPOSAL FLD -- - , NE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC TIONS. 2�� ❑ Industrial '--- --'-;If Open Bottom-- -❑ Manteca - '- Dia. of Well Excav�a.+doy°' -- Dia. of Well Casing _,__0 Domestic/Private ❑ Gravel Pack --O_Tracy--- Type of Casi • _ Specifications C1 Public ❑ Other ❑ Delta Depth of Grout Seal �TvType of Grout "..-. ❑ Irrigation -.. . - f P m. Depth ❑ EasternSurface Seal Installed by Re it Work Done ❑ T ,___H.P.. State_Work Done yyyy II qestruction �I/ Well Diamet�rp,��—{nom SealingMaterial(top50'1 U�TOt -'Depth _` I" Filler Matedal(Below X50') ,- TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION Wo septic system permitted if public sewer is available within 200 feet.) . ..Installationwill serve: -Residence_ _Commercial_ Other Number of Irving units:_ Number of bedrooms j Character of soil to a depth of 3 feet: - -'- - �"-""-- � Depth - Water table SEPIIC_TANK. _ t__. ❑__Type/Mfg I I Capacity No. Com -Limens PKG. TREATMENT PLT. ❑ _ Method of Disposal Distance to nearest: - Well � Foundation Property line LEACHING LIN � I �- ance to nearest- 1- Well --1'-i-Foundation Pr length/size ❑ Dist FILTER BED • -- _ __L - Property Line - - -- - I--- - E ❑ No. & Length of lineal Total lengt • j i i DISPOSAL PONDS _C]-'i- hereby r I ( { Number I SEEPAGE PITS ❑ Depth S ►-� SUMPS d Distance to n�rest:� Wf lsllt-� -+ Foundatron + Property Llne I ��__ .._ cert that I have prepared this a Iicallon,and that the vJo*MI be done in accordance with San Joaquin county ordinances, state laws, and rfY P Pa PP � J- rules and regulations-of the San-Joaquin'Local-Health District"tom Home owner or licensed agent's signature certifies the following: "Icertify that in the performance of the work for which this permit is issued, I shall not [. e -- mploy any person in such manner as to become subject to workman's compensation laws of Califomia' 'Contractoes hiring or sub-contracting signature- { certifies the following: I cert- that in the performance of the rk for which is rmrt�issued, I shall employ ) - compensa- tion N pe I{- yro y- tFt--{peI p y persons subject to workman's co --bon laws-of California.- The _See pfca at call for all uire Completeld g p{itt.�ray� a./ �e /� /s I Date. _ l f �- �RISE ` { ' ONLY I iPPlication AccaPted [)are ate real Pit or Grout y Date Final onby Date, Additional ao�. AdditionalComments: ❑ Stk- 81- rQ-Lod- " O,Manteca1823-7104` -T❑Tracy- "-[ -._- - 1j t •: Applicant Return all copies to: Environmental Health Permit/Services 1601E Hazelton Ave P.O. Box 2009 Stk.yCA_961201 � I-FEE _J MOli�1T DU� MDUNT IAREMITTED NECEIVED BY DAPERMIT NOTE { - NFO CASH s EH 71M(REV.1/951