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or I ' APPLICATION FOR PE"!T SAN JOAOUIN LOCAL HEALTH DISTRICT 1601 E. HAIFLTON AVE., STOCKTON, CA " Telephoge (209) 466.6781 PERMIT NU, ' k; r PFRMfT FfrPIRFS I YEAP FRIM DATE ISSUED GTE iSSEt£Q ' (Complete !n Trfplicatel I Application is here,Y "�aQe to the San described, Thi Joaquin Local Health District for a permit to construct and/or install the rcrk t+ere4n f and the Rule $ apl'lication is made in compliance with San Joe in Count Ordinance No. 549 for sera a Or R sand Regulation o t Sen qu Y Job Address. e - quin LOC41 Health District. 9 No. 1862 'ur well/pump Owner's Name �5ubdivtsi n Name Contractor's Nam Address license No. Phone {� TYPE OF ►IEE ---E/PDHP WORK; �� - NEW WELL [] WELL REPLACEMENTZOMMUMMM 4S PUMP INSTALLATION (� ❑ DESTRUCTION 0 DISTANCE TO NEAREST: SEPTIC, TANK SYSTEM REPAIR ❑ OTHER ❑ t �! SEWER LINES n DISPOSAL FLO. i FOIINDATIflrI P17!`P. LINE ~---- � ___ AGRICULTURE WELL p�R WELL IHTE`lOEp USE "�-^- _ PiTS,riN"S Ft"£ OF WELL PROBLEM 41 ,- Industrial -_j len Bottom PROSLFM AREA Eq CONSIRKTiON SPECIFICATIONS;❑Domestic/Private Manteca Dla, c Of Well Excavation i []Gravel Pack ❑Tracy Die, of Well casing , ❑Public - LI Other ❑GiG c ❑ Irrigation A Type of Cali PPrvrt. ['�Eastern n9 R ' . . ❑Cathodic Protection Depth Specifications ❑GophYsical Depth of trout Seal L]Other Type of Grout It Repafr Work Done❑ YPe T of Surfac! Seal Installed by Pump M.P. Well Destruction 0 Weil Diameter State Worn poneDepth n j . `Sealing Material (top So,) Filter iatertai (Below SO') = U i.• TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADOITION 'Y ❑ (110 septic tank or &"ge pit pensitted i! public sewe- is Installation will serve; Residence ,e Coetnercial Other available within 200 foot;) Number of living units; -4-L Mimber Of as. Character of soil to adepth of 3 t: Lot site �.r ' s4 i SEPTIC TANK r �1 Ty" Mfg . Rater table depth PKG. TREATMENT PLT. n Type/Mfg Capaetty _� No. impartments Distance to nearest. 4wity-T' Method of Dispos�I FbowLEACHING LINE --=— Properly Line No. d Length Of likes FILTER BFO Total ength/stzy' r ❑ Distei:ce to nearest; Well ; SEEPAGE PITS Drpcn - - Fow►datton , P►oPerty Lina SUMPS Site �• 1lissber Li Distance to neares.; Wall DISPOSAL PONDS . �. ._Foundatitrn y [1 � Property tine 1 horaby certify that I have orr'pertrd this application and that the Writ w111 G done 1n accordance with San ordinances• stat, laws, and rules and iipnse weer regulations Of the San Joaquin LDCGI Mealtb ptstriet, Joaquin county 0 or Licensed ng^,t's siggnnaRture earilfios-the folletHn ti pet Is issued, ! shell not rnsPloy any Parson In such manner as to bertify that 1n tha•parfornance of the work for whirs this a Contractor's hiring d. sub.contrect+n signature eCO�e subject to ++orlremnt C I this panwlt Is issued, 1 shell ea Tog si ature certifies the followtiq: I certify that in the perf Batten oars of California," P y persons subject to workaun s c P+rforarance of the work for which The applfe t must ca�1 for ell required ins �Pesrsatlon Tarn of California." Signed A ~ � Portions.' Complete drawing on Cie $ide. K Title: �S J � AP cation Acceptrd by FOR DEPARTMENT USE ONLY cats-, li Additional C&m"ts: Area t "�r��,rs66-6)81 j Pit or Grout inspection ------ L041 369-36?1 Final I+,spection by cat [� Nlnteca 823-7104 j Applicant - Return all copie o; Environ Cato Tracy 835-6385 1 Health Parawlt/Services 1 i E. lttsalton Avg., P.O. OW20094;tk., to 95201 FEC BASE AMDt)`!T IWC INFO ,_ MOUNT REMITTED a RECEIVED By DATE PERMIT N0. I H _ i' Ell 13-24 REV, 14;n2 r ` 5 14-26 I 10182 500