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rp .. APPLICATION FOR PERMIT '1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. H'kZELTON AVE., STOCKTON, CA �Jh`•r; Telephone (209) 46&6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) } Apo licatlop is MI eby made to the San Joaquir,Local Health District for a permit to construct and/or Install the work herein described.This appees N 5 made in compliance with San Joaquin Count/Ordinance No.549 for sewage or No.IBM for wall/pump and the Rules and Regulations of the Sen Jopum`. p Local Health District. ="<� JobAddress _]7i1 f 6W! t _ City t Lot Site J p L f� PM 'rt 3e Owner's Name �+ — AddPhone ., _�/�L.d, Address ' W Contractor }t� C.. 1e�ress 350C -4L f�t License No Ll z.n'R39 -hone TYPE OF WELL/PUMr: ..,'.NEW WELL.O WELL REPLACEMENT ❑ _.DESTRUCTION O PUMP INSTALLATION ❑ SYSTEM REPAIR 13 OTHER ❑ , DISTANCE TO NF;4RE5T: SEPTIC TANK -' SEWER LINES" ' DISPOSAL FLU._' PROP. LINE .. FOUNDATION.+ AGRICULTURE WELL OTHER WELL PITS/SUMPS y X� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom O Manteca Dia.of Web Excavation Die.Of Well Ce'In g 1 1- ❑ Domestl;!Privete 0 Gravel Peck - O Tracy -Type of"Casing - Specifications f7 PublicC1 Other ❑ Delta Depth of Grout Suet Type of Grout «, g I I...gat"n Aprnos. Depth 1 1 Eastern Surface Saul Installed by; — ,r Repair:N ork Done ❑ Type o1 Pump -State Work Done__ '• a Welt Ce,r Iruttion Or 'Nell Diameter -Sealing Material Itop 501 -' Depth Filler Material(Below 50') TYPE OF SEPTIC WORK .NEP/INSTALLATION I 1 REPAIR/AUDI IION STRUCTION I I INO septic system permitted if public sewer 6 OF, available within 200 feet( i. Installat an will serve' Residence__ C/ommer<lal -Other Number o1 living units: Number of bedrooms _ Character of soil to a depth of 3 feet:—�r`�A�' y Water table depth ' SEPTIC TANK -T7--7Vpe/M/9 —>--r.+-p�L>=r� It CapecitV-19� No. Compr,rtmenis PKG,TREATMENT PLT ❑'i - Method of Di \\ Distance:o nearest: Well j0_0Foundation_ Property Lme_ LEACHING LINE Q_-No. d Length of lines oral length/sire ee��.snr-stJ —---- FILTER BED ❑i Distance to nearest: Well�t Foui,6abon VV Property Line SEEPAGE PITS— IV-9opthSire " Number_�� n sum-i, perry Line r• fe ❑� Distance to nearest: Well�((,.`(�— Foundabon Pro DS O IDISPOSAL hnre S certify Khat 1 have prepared thisapplication and that the work will be done r a t a t 1 m accordance with Sen Joaquin county Ordlmncef,stere laws,and Home and owner or licensed of thejSan Joaquin Local Health District Home owner or IicemM agent's signature cartifbe the following- "I certify.that In the periarmance of the work for which this parm3 is issued i snap not ofi�hgLany person m su<trrtiennor ds to become subject to workmen's compensation lay. Of California."Contractors hiring or suAconered4p spnstdn comfiest following."I 'ly-that in the performance of the work for which this permit is issued,I&hall employ persons subject to workman s eornalre y. tion lawn of 'forniaJ . .The applicant m Coll for e'I Onus Ins Iom, to drawing on rayeraeside - S - Title q Oats- �' r I FOR OBFARTMENT USE ONL is c Date J.^ �'S" 7 Aree Application Accepted by t j ;.0 • I at Final Finel)nePoction by i'c eYl.b Date jr _Pit or Grout.:impecuon OY;. ` �.. -�-,.. Comm [D Stk p4 6-6781 oro: ❑ Stk 466-6181 ❑ lodl 369-3@l : e tit u Seo,ic t E. az Y 8358,P.O. lr Applicant-Return a copies Environmental Health Permit/Services 1607 E. Hezadon Ave.,F. Bos 11169, St4.,CA!S20t - FEE A MITTEO � 4n R OAT VEAMI11N�[OJ9 Jtj INIT — H v.]e —� yvAy f 5.. +.> +iFV"in+t'Na4�efl^,ne,w -' ,A. 1•I.:K} t�yv% ^� n)f�,.k� T� i