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r ' c Fi+wy i; r wit 'c y APPLICATION FOR PERMIT. � k 0 SAN JOAQUIN LOCAL HEALTH DISTRICT d. 1601 E. HAZELTON AVE., STOCKTON CA f Telephon6.,0091466-6781 u PERMIT EXPIRES 1 YEAR FROM DATE ISSUED xtl (Corterete 7. in i riplicate) Appfxation it hmaby made to the San Joaquin Local Health Districtror s pem[it to Construct and/or install the work herein described: [io This appl+can Isitl �. made"in compliance with San Juin C oaquounrytOrd+ndnce No 549 for sewage or No 1862 for welllpump and the Rules and Regulations of the Sart Joaquin T :*LOtil Heath rCt " Job Addresa� City_ 'Lot ti� wi - r } �Owner Name ess~' Phone r � Conlraetor' cress License No. PhoneN "+ a7YPE OF.,WELL/PUMP; ��rxNEW WELL ❑ : WELL REPLACE14fENT DESTRUCTION PUMP-INSTALLATION ❑ <' SYSTEM REPAIR ❑ OTYER © ' DISTANCE TO NEAREST" SEPTIC-TANK SEWER LINES DiSPOSAL,FLp PROP..'LINE F � 5 y; FOUNDATION F -__AGh.t,ULTURE WELL OTHER WELL' P]TS/SUMPS _i r 'INTENDED USE r + - TYPE OF WELL '•PROS LEMAREA CONSTRUCTION SPECIFICATIONS v Jc ',i, c r}•' 'vhf �r L}Industnal [�Qpen Boitom ❑Manteca Diaof Well Excavation Dia at Wel[Casrnp ?i�� I � r � � D Dt>rrrestic/Pnvate `❑Gravel Pack ,� z ❑7raty Type of Casing Speclficatians 'g44rl Public U Other r i n Delta t]epth o!Grout Seat Type of Grout. y 4. �k .1 'r]I-Irrglatrorl .> Approx Oe>+th t.I Eastern Surface Seal Installedby— hu 4 Repair Work Done (] Ty1,e'of Pumps H P. State L+ork Done ' Wef1 Dastructlon ❑ t-Weft Diameter Sealing Material,{top 56'1 r^'. Depth Filler Materia]iSelow 56) " a ?'xra qf�i� �4 ry r STYPE OF SBPT]G WORK NF ENSTALLATlON REPAERlAODITIDN l I DESTRUCTION IJ {No septic system permitted if public sewer n' t ` a a availabla within 200 feet 1 nt , a'+; � �'j ylnataaatron vwtl serve Resiod ice °Commercwf Other x iX R i Number of kwng UMII t Numbor of Brooms' i kH -Character o!soil to a depth o!3 feat Water table depth ai ^ sSEPTIC-TANK 3 } �- ?-.. {❑ TypelMfg =Capacity No. Compartments,' �cKh,k s EKG TREATMENT ALT ❑ ;; ' Method of Disposal. 'I Ince to nearest Well �� Foundation L'�' Property Linen 4 LEACHING LINE "� r,t igth of linea d'` Total length/size �} a FILTER BED ❑ 1.atance to nearer: Well Foundation� Property Line S� # ;. °; SEEPAGE PITS I I Depth' Sue Number SUMPS ✓„L� Distance to nearest: Will Foundation Property Line rt DISPOSAL PONDS+,-., 3• a I hereby"Carlify'that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws- and 7 rubs and regulations of aha San'Joaquin Local health District. `+ + 'Home owner of licensed r2ent'sscgnature certifies the}ogov+ring:"1 certify shat in the performance of the work fa which this permit is.asued I shall not erl s• employ anyperson In such manner as to become subject to workman's compensation laws of California. Contractors hiring or sub-contracting signature A cerLfies Itis following i CB}Ufy t t rformanca of the work for wNch this permit is issued.I shall employ persona subject to workman's - sir : �L•'tion laws of Ca]itornca t applicant” ;t or raqu!red r tions.Camofei rawing on reverse side. l„ et r Srpned .Title Da[e: q] r 1 FOR DEPARTMENT USE ONLY • >+ x �+ Applrcation Accepted b Oates G r Pit or Gcvut Inspect by Date Final inspection by.C�!'._" �l �'-' Data i j^s�'f7 .y Additra sal Corteasntf - �' :..�. _�'ti�; _- _— ,��J f v .3 Fy�'1•f,.err ❑ ik 4fi6 6781 - , .❑ Lodi 369.3621 �anteca 823.7160 ❑Tracy 835.6385 t Vq` 5 be 4n ". r Applicant Return as cop+is ro Environmental PermitlSarvccea 5601 E.Harahon AWOL,P.O. Box 2009,Stk.,CA [NFO AMOUNT DUE ,AMOUNT FEMIITED' ASN RECEIVED BY -t• ' t � r y DATE PERMIT NO.'• 4 ?� - tM � � I y f