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APPLICATION F OR PERMIT P AV E 1',l-r 46 SAN JOAQUIN LOCAL HEALTH DISTRICT R r- C: E: l V r_p f 1601 E. HAZE T ON A E., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEA FROM DATE ISS 0.4 w ^r S (Complete in 'Triplicate) f 1 �I Application is hereby made n the San Joaquin Local Health District for a permit to construct and/or install theworkheroin described. This L\r\'�.. made in compliance with San Joacation is quin County Ordinance No. 549 for sewage or No. 1P62 int well/ um Local Health District. p p and the Rules and Regulations of the San llJoaquin Job Address vl 5 City 4 0 Lot Size 1 Q _ PM Owner's Name—ApV Q Qt-!� bA,A I/ - __- Address _)_00„S L� Qs��Y�'�� -- T t a �!• PQ �—_ Phorre �l ContractorL� �gf� ^' rpl�dl);cnR yS:iB � TYPE OF WELL/PUMP: - License Ivo. NEW WELL I-) WELL REPLACEMENT ! ] `� �__.-.. f'For>c�yl oy ��- - -- PUMP INSTALLATION i-I DESTRUCTION DC DISTANCE TO NEAREST: SEPTIC TANK SYSTE REPAIR 1-} OTHER 17 ---------__. SEWER LINES �_ DISPOSAL FLO. FOUNDATION �— AGRICULTURE WEL — PROP. LINE ... __ INTENDED USE OTHER WELL _ PITS/SUMPS TYPE OF WELL PROBLEM AREA CO,NSTA CTION SPECIFICATIONS— _ fndustu I l=1 Open Bottom --- Manteca Dia t of ell Excavation Fl Domestic/Private [.l Gravel Pack � J J --- Dia. of Well Casing - ii Tracy Type of Casing____ (WI Public K Other Mp `*. t 11 —_ Specifications -`- a7 PQM Fi Delta Depth of Grout Seal [1 Irrigation -;. Type of Grout �'Approx. Depth la] l=astern Suriace�_5eal Installed by Repair Work Done C- ype of Pump �, H.P.. State Work D ne—� a Well Destruction//K NWell Diameter _ ~ / gam— Sealing Material Ito 50'1 Or1,t / Depth_ ' rRul or, Sowrl�Gw1 Filler Material (Below 50) ✓'urn TYPE OF SEPTIC W K: NEW INSTALLATION (1 REPAIR/ADDITION I i � 'x"417 ESTRUCTION [71 (No tic's stem v 'system permitted if public sewer Installation willserve: Res nee , rlable wiihin.200 feet.) 'N Cornmer'ciai Other _ Number of living units: tuber of bedrooms ~— Character of soil 1. a depth,of'3 feet: 1` Water table depth i SEPTIC TANK L1�,Type/Mfg _ ppp PKG. TREATMENT PLTI Capacity_ 11 F f +. �--- No. Compartments P Distance to nearest: Method of Disposal _ ell Foundati n I Property Line ( w. LEACHING LINE ❑ No. & Length ofIon C] Di FILTER BED p F Total lehgth/size_' — Distance to ne st: Well ! Foiindaton �— — ---- l + --- Property Line SEEPAGE PITS I-] Dep _ Number SUMPS [ I )stance to nearest: Well ---- ~� i DISPOSAL PONDS Foundati n _ Property Line I hereby certify that I have prepared this application and that the work will be don in accordance with San Joaquin county ordinances, state rules and regulations of the San Joaquin Local Health District. laws, and Home owner or licensed agent's signature certifies the following: "I certify that in t Ie performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensaiidn laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issuedI shall employ tion laws of California." , p y persons subject to workman's compensa- tion applicant must call for all required inspections. Complete drawing Artac�t� Signed X /�• r �14t 4 - �'� b e ct I ro-f — _ Title: _ rofl-t.l (�Po�� ; Date: �' FOR DEPARTMENT U E ONLY Application Accepted by Pit or Grout Inspection by u -- Date Ira &kr Area Date Final Inspection by L Additional Comments: Date >, ❑ Stk 466-6781 ❑ Lodi 369-3fi21 ❑ Manteca 823-7104 L] Trai y 835-6385 Applicant - Return 811 copies to: II Environmental Health Permit/-Services 1601 E. Haze ton Ave., P.O. Box 2009, Stk., CA 95201 Fr�� " VVV4Qd! IOr.�w o ��w7[ g pS��'E AMOUNTRE D RECEIVED BY CASH DATE PERMIT NO, EH 13-24 IREV,