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.3 APPLICATION FOR PEWIT SAN JOAQUIN LOCAL HEALTH DISTRICT • 1607 E. ifAZELi0N AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Trip irate) Application is hivehy made to the San Joaquin Local flcahh District for a permit to cnnslnicr afid/or irintall the work herein doscr;bed.This epplication is made in cnn+pliancu will'San Joagtiir.County Ordinamu Nol'Aq for sew,ipa nr fvo. 16112}or walllpurnp and 11+u!T uieS and Aoipations of the San Joaqu+,'+ Laval Hcahli Dist+raIcctt... T Job Address _,.__L� .._ �Cr:xL.ls S --- ------- City._�L .�— Lot Size PM Owner's Name _ � :`�:�CP l,dr3rrrss ---.-- �__----- Phone lo_ Cor,!tactor_� ':1:.11.:- "-21:;d-7i ::ate-r_ A iIress 9 �+.�wl�- u EV{rr�icerise No. —^Phone TYPE OF WELLlPLIN. ' __. , NEW WELL 13 WELL REPLACEMENT (_I ()ESTRUCTION L) PUMP INSTALLATION 1.1 SYSTLM REPAIR CI OTHER El i) DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES _ DISPOSAL FLC.._-- PROP. LINE µ FOUNDATION AGRICULTURE WELL OTHER WELL_—�. PITS/SUMPS INTENDED USE — TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial U Open 90ttom i i Manteca Dia. of WeII Excavation_.._— __ Dia.of Well Casing — Ll Domestic/Private I-] Grave! Peel l 1 Tracy Type of Specifications I'1 Fublic 1-' Other 11 ciclt.t gepih or C,rout Seal _ _ Type of Grout,_._—_ ---_ ! l litigation ___. Approa. Depth 11 Eastern Surface Sodl Insl JlEed by __.�._.----�• — ` Repair Work Doric 17 Type. if Pump _--.__-- ri.Y._--_ _�...--__— State Work Done— Well Destruction _l We!] Diameler r—___ Scaling Material!top 5011 __---- --- — -- i A filler Male•°,i [Below 501 —.-_-- — �— -- i TYPE OF SEPTIC,WORK: NEW INSTAI-t.AIIGN I } RLI'-.lF;1^ )N ! I rMSTRLICTION 7 (No seplw systnm permilkrd if uuhiic sewer is i avcildtdu within 200 feet.l Installation will serve::. Re dente Ir Commercial_____ 0:75ul _� t I Nurnbef of living UMM , Number of bedrooms--,7——. 1 Character of soil to a depth of 3 lle t. __.__. � Wafer!able depth _ { SEPTIC TANK TyFe17Afg _— __ Capacity— Nu, Compartment- j PKG. TREATMENT PLT.Ll Method of Disposal II Distance to nearest: Well—_ Foundation__ Property Line } __—_ Total Ian th7size LEACHING LINE L.l Na. & Len!13h of Eines _.��_,—_ 0 O i FILTER BED LI Distance f, nearest: Well Foundation Property Line l� SEEPAC51 PITS 11 Do pin Size -- Number ? SUMPS L1 Distance to nearest! Well Foundation_ Property line DISPOSAL PONDS IJ I hereby c� artify that I have prepared this:application and that rho work will be done in accurddnce with San Joaquin cnunty ordinances,orate laws,Znt1 ] ruler and regulations of the San Joaquin Local Health Di1trict. I` Home ownsr or licensed agent's signature canities the following: "I certify that in the performance of the work for which this permit is issued,!shall not employ m.y:xlr_f)n in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-Contracting signature I canities:ha ioirowing:'•I certify that in the perforrnanco o1 the wit%for which this permit is issued,I shall employ persons subject to workman's cnmpensa von!aws o1 Catiiornia." The applicant a call for I �fsqut.adinspoctions. Complete drawing on reverse �s`ide. [1 C 1'tt c Titl©:!moo " — late: _ '.�7 8 Signed X� _ __ —____T —FOR DEPARTMENT IJSE ONLY y,gplirat;nn.Accegtad by ---- •— Caro Ar Pit or Grout Inspection by DO to _ Final'inspection try ' __T I Additicnnl Comments: �---may-- D Stk 456.6761 ❑ Lodi 369.3621 0 Manteca 823-7184 ❑'fracy MS-638 APPlicsnt- Return all copies to: Frivirr,nmental Health Permit/Services 1601 E. Hazahon Ave., P.O. Bax 2008,Stk., CA 95201 FEE AMOUNT DUE AMOUNT AEN[TED 1 CASH AECE1VED BY DATE PERNp7'NO. INFO ---= " 1 fM i47a i