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y L APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED Inlif 15o:f (Complete in Triplicate) v�u�1 L�1J�e'�Tt,1� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the w�1(Re1aM�gfesYppzdtidn is made in compliance with San Joaquin County Ordinance No.599.for sewage or No. 1862 for wall/pump and the Rules agglp1�d111 52111f illi%an Joaquin Local Health District. '�7 Er. ) �-1 ,,(, T Job Address 7 5 / C. 114-i .T/�✓�'L�2.1 Ci ry t�— Lot Size - PM / Owner's Name 441.0'. 1Inr 'L .Address a 5 0-ZO6XIL Phone 432— S -}- 5CG&Jove OS d S-74PA.+ Contractor -WaIteir W Address.1?1 D MQi w 5+ LiceWX. !a�(a'7D Phone - TYPE OF WELL/PUMP: NEW WELL." WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER V. Sar DISTANCE TO NEAREST: SEPTIC TANK �V60/ SEWER LINES 2.100" DISPOSAL FLD. __i PROP. LINE. FOUNDATION IrXNL AGRICULTURE WELLe)O OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION El Industrial ❑Open.Bottom ❑ Manteca Dia. of Well Excavation/I' Dia. of Well Casing Z ; Domestic/Private WGraval Pack Vfracy Type of Geeing / Specifications 11 Public n other n Delta Depth of Grout Seal T of Grout S� 1 1 Irrigation —Approx. Depth I I Eastern Surface Sea] Installed hvS7Q3eL� _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filter Material(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer.is vailab4o within 200 feet.) bntWatbn will esnae: . Residence' Commercial—'Other Number of-Cupp unite:_ .,Number of bedrooms \ Character at soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Comper[rronts PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING UNE.,14 No.8 Length of lines To /size FILTER BED � ' r Distance to nearest: Wall Line ov SEEPAGE PITS j /�IIII I I Depth Size Number SUMPS N O Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ,.. ❑ I hereby certify that I have prepared this application 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 kea sed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall not employ any Parson in such-roamer as to become subject to workman's compensation jaws of California."Contractor's hiring or sub-contracting signature certifies the foaoswg:"1 certify.that in the performance of the work for which this permit is issued,1 shell employ parsons subject to workman's compensa- tion laws of California." The applicant.mu t call f as required' ompste drawing on reverse side./`� %� S Signed X--` xyl t/. Title:�a�AN �7E.r'J/eX1.1t1� Date: �! FORMPARTMENT USE ONLY Application Accepted M L�y� � Date Area ga� Pit or Grout Inspection by OAS/ Date 18 Final Inspection by Pae Q Additional Comments: ❑ Sdt 4668781 ❑ Lodi 366-3021 ❑ Manteca 823.7104 ❑Tracy 83"M Applicant- Return 46 Copies.to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2D09, Stk., CA 95201 - µ0 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY pDATEG.,p. PEERRWVND. .EH uar tRFV.tixu 3 s 3 SAl �.+�7 "./. �• ► 1 en ILt•