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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 7 ' 1601 E. HAZELTON AVE., STOCKTON, CA \_ Telephone (209) 466-6761 f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I 'n ";J (Complete in.Triplicate) F t� XjI T f'-r, -C' Application is hereby made to the San Josquin Local Health District for a permit to construct and/or install the work herein described. This tlppIcafto b made in compliance with San Joaquin County Ordinance No.50 for sewage or No. 1862 for wep/pump and the Ryles and Ragulatlom of the San Jaagakn .-- Local Health District. Job Address 1S2J.J •• � \ „r'••'��/1r_i"�-'`i`^"' city Lot Sim; = . . nPM l Dwner's Name 60& j ^-� -Address'..7030 & Phow uu JJ ��-rr ' PQ$Gx 7b> a4' agaa� Ifiarb 6 'sive ` I Contract M ��7�C1At Aaw�CR Address license No TYPE OF WELL/PUMP: NEW WELL ❑ —WEL'I7REPtACEMENT-O- —" DESTRUCTION-❑' i PUMP INSTALLATION O n .SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' ( } I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS fi ' I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFCATIONS , i❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Welt Casing " 1❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ [)site Depth of Grout Seal Type of Grout_ ' ❑ Irrigation ---Approx. Depth ❑ Fastest Surface Seel Installed by 1 Repair Work Done ❑ Type of Pump H.P. State Work Done i { Well Destruction ❑ Well Diameter Sealing Material(top ` r Depth i Filler Matfefial Below 50') I TYPE OF SEPTIC WORK: NEW INSTALLATION i EPAIR/ADGo1T0 O DES TRU_n_f)V 'INoa�syetamm pe med itpublic awrer Is ` ithin 20D feet.) Installation will serve: ResidenI ce Commercial Other 1 t Number of living units: Number dro y � Character of soil to a depth of 3 feet: - t ata table depth a0 SKEPTIC TANK g Type/Mfg 1 n t Capacity .,'--'No-Co `', P CG. TREATMENT PLT. ❑ i r \ r 4 MZthod f 0i�poFalh i Distance to merest: Well yt u IF .Marion I 0 [ Property Lim � a0l,.X LEACHING LINE lX No. 8 Length of lines „ — 4D Tow lerngdvs¢e FILTER'BED G Distances to nearest: well j,?O Foundation IQ I Property Line � 31 ya" SEEPAGE PITS fd"Depth �S -S'Qe F�ynnbar r r f>�7/MPS ❑ Distance to nearest: Wap /5'Q Foundaruw /6 DISPOSAL PONDS ❑ t I Tiereby certify that 1 have prepared this appl'icatbn and that the work will be done in accordan,i,,with San Joaquin county ordinances, state laws, and r ru�ea aM-+aguletions-ofthe-Ssn-Jouin-L�al�lea/th-District. - tY>'F'�`,t "--"'^'� Home owner or licerceed egem'a signshnre mortifies the foppwirg:"I certrfy that in'1M patfortnenre or the wodc for which this perm-is traced, i igne not ,empbY any.penvon-inwuch-nenner ac-tobecome-subject-to-vrorkman'amrtnpensetion aevwvf C9pfomia-=•.C-ontncersomirin jest to workman's compensa- te, oignatt a- certifies the folowinp:"I certlfY the m the performance of the work for which chis pemst K isstwd.1 shag employ peracna subject to workmen's compensa- tibn-Iews of California." �,� � �;{ c Tha appTuM m t cab 10 ep ukad inspectiae. Compote drawing on reverse side. � _ „--, _ - • te,.4 f / FOR'_DE—PART/pMENT USE ONLY ,/ r �•`. //A''pplicabon Accepted by /"'`� — Gets u/ Ates -f ►dor Grout Ine{Mefbn tryf�a(WZZUOete l(/ Fbtal.lnapeclion by Data kOAdditional Comments: AJC ❑ Stk 488-8781 ❑ Lodi 380-3621 ❑ NYmxa 823-7104 o Tracy 83&4M5 Applicant- Retum all copies to: En~I son td Hsa-h Pernnit/Services 1801 E.HtnNtan Ave., P.O. Box 2009, Stk., CA 95MI FEE AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERP NO. INFO ` . �8s EH 1]-an nary.vast O I4a1