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APPLICATION,FOR PERMIT-` SAN JOAQUINIOCAL76ALTH DISTR�I/CT 1601 E._RAZELTON.Ay%.-;.STOCKTON, CA Telepho4e( 1111466-67811 , JB8-r9 t zURc� zissTJz to P mist) PERMIT EXPIRESA,iYEAR FROM:;DATE-ISSUED to »ni tLi-0 oiJsgzs tou2aeaubstsvoopnibulanl,2sTutoUti8Womplete iri'TripliEate) c"tris zenlituobe,rloian9miG Application is hereby made to the San Joaquin Local Health District for a i permit t0 construct and/or install the work herein described This application is r<,`made in compl`isnce Whh' n�o�quin�our�tY rdinaii bS Sq9 rrsewa ..... No lia {or well/pump and the Rules and Regulations of the San Joaquin Local Health District's-I '-U�IJL. YiptC { PR`Ct t r - v-1< / � rt 'ZZf 1 . / �,/✓f �� JTOpo1�rlf nc C � �� . . ; , �r1Jo to nor)s^ j� c Job Address V\/ - a " n %, - City Lot Size PM - ,. Addreas7 Pho I. _Contractor. • \ ►Y y Cr AddresszS L` - _License No. - Phone TYPE OF WELL/PUMP: NEW WELL ❑ ----WELL RIEPLACEMENT,❑ --_ DESTRUCTION - �111wi WcI) Z PUMP INSTALLATION ❑ j SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST- SEPTIC TANK SEWER LINES - DISPOSAL FLD -PROP. LINE- T e FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE 1 ' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFI&T'IQNS O Industrial- - ❑ Open Bottom P ❑ Manteca Dia.-of Well EzcaTi3ti6rr - - i -__ I yl J Dia. of Well Casing _ - ! _ [I Domestic/Private _'❑ Gravel Pack ❑ Tracy Type of Casing' , Specifications ❑ Public ❑ Other I Deto- __ .Depth of Grout Seal T CJC (,T R -. - ❑ Irrigation -- t� 1 1 . ' Ype of Grout ; t^ t r g —App&-Depth ❑ Eastern Surface Seal Installed by '-- "--"- '-- --- - ` - - - _- _. Re it ork Done ❑ Type of Pump. H.P. ' State Work.Done - - �IIY)gstrrurtiorEl f Sealing Material (top 50') TT 1I�R1 _ Dept jo 70 Filler Material(Below 50') TYPE TYPE OF_SEPTIC WORK:., NEWINSTALLATION_❑ REPAIR/ADDITION O DESTRUCTION ❑_tNo septic system permitted H public sewer is .__....-_ .. available within 200 feet.) . Installation will serve:- Residence_-Commercial—.Other --. _ .. Number of living units: Number of bedrooms j Character of soil to a depth of 3 feet:-` - - - - -- Water table depth - _. SEPTIC TANK . ..- . . _O -_Type/Mfg Capacity -- No. Compartments- PKG.TREATMENT PLT. O Method of Disposal Distance to nearest:-'. Well l- Foundation Property Line� I I i i I r NE LEACHING LI ❑ No. & Len th of lines I i i i __ 9 Total.length/size �- FILTER BED - � - ❑- Distance to nearest:-i Well 1 Y t Foundanon Line -� SEEPAGE PITS' ❑ Depth Size I 1 I Number ' L ; _ __C3 _ 1 '--- --------- ❑ Distance to nearest Well T --r Foundation- - -- Property Lme 1 .._DISPOSAL PONDS.! ❑ __ Y certify prepared application h �— -__•.in - _ -•--h S ' I hereb certi that I have re red this a lication and that the work will be done in accordance with San Joaquin county ordinances state laws, and -. -' - rules and regulations of the San Joaquin Local Health District:—)' Home owner or licensed agents signature certifies the following: "I certify that in the performance of the work for which this permit is-issued, I•shall not }-- -l---employ any person in such manner as to become-subject to workman's-compensation laws of California:"Contrac'tor's hiring or sub-contracting signature L —The a licent II fo I re i o dravnn o which this permit is issued I shall employ persons subject to workman's compensa- certifies the fol n I ce that'n t work for wh -tion laws of Irfo ra." ._ _. g:" performance of the I i PP l Plater g h; ( g i. _�._' .�_ FOR DEPARTMENT USE ONLY /r�J.,-,/� Tnle _ _ 1 at e 1 _ J-�t---- I Application Accepted by �I i -_ Date i Area - �- 1.._ __t- - RPh orGrout Inspection by Date I Final Inspection by Date -... ... ._ Adadwnal Comments: ❑-Lodi 388-382 ❑M71041 i I l .. `---�-"08tk--488-8781 `-- - 1-�'- ( �❑Tracy -8356385 - - --- - - AppBcent-.Return all copies to: Environmental Health Permit/Services 7601 E. Hazelton Ave-, P.O. Box 2009, Stk., CA 95201 ` 1AMOUNT D , (NPO UE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. rM I ---44' 134--J- t Ell 13ZI(REV.1/851