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} Li / APPLICATION FOR PERMIT ' I SAN JOAQUIN LOCAL HEALTH DISTRICT f^ �+ 1601 E. HAZELTON AVE., STOCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 1. I: Job Address Pi City of Size M Owner's Name _` e' 0. Address.212 lar e.'M oti.-4:!jQj Phone ` Contractor - • AtldressT �C l Z+/ License No. L 7 Phone vZ TYPE.OF WELL(PUMP_.__,,,,��.,.NEW.Y✓ELL.f7 /-. WELL REF,LACENIENY❑ `DES_T_RUCITIO_N_❑ ,__y- �_ _ - PUMP INSTALLATION 1- SYSTEM REPAIR _–AT CR O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 1 PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications f"I Public ❑ Other ❑�Delta Depth of Grout Seal Type of Grout--- �ation // _Approx. Depth IKEastern S rfa�cB7 Saul Installed by I - Repair Work Done L] Type of Pump n w.r. H.P. State Work Done_ hS -•Well Destruction ❑ Well Diameter' Sealing Material (top 501 - Depth _L, Filler Material (Below 501 TYPE OF SEPTIC WORK:`NEW INSTALLATION 1.1 REPAIR/ADDITION I DESTRUCTION I I INo•septic system permitted if public'sewer is available within 200 feet.) r I-f 4 Installation will serve: Residence— Commercial�� Other -- -'R-• r Number of living units;,` Number of bedrooms ` (�' •� .) Character of soil to a depth of 3 feet: ) Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal • r Distance to nearest: Well uhd n Property Line • LEACHING LINE ❑ No. & Length of lin ^A.. Total length/size FILTER BED 11 Distance to n6fres ,.` well .4 ' 'J Foundation_ Property Line t SEEPAGE PITS I I Depth '' ize Numbs SUMPS LI Distance to nears WNI Foundation' at1 1 "Pr6pe Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate laws, ant rules andregulation San Joaquin Local Health Dittrict. L Home owner or -sed ag is signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not employ any s in such nner as becom loci to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the one ng: "I 'fy at i the d rice of the work for which this permit is issued, I she)]employ.persons subject to workman's compensa- tion laws t Calif r ' nn -- The app cant st for ctiio s. a -awing on retr�6 de. %'.,�/}�/f � �` - Signed '00. Title: ` .I KSI'—X-� Data: /A2 7 R DEPARTMENT USE ONLY Application Accepted by Date �" `F'�II� Area P Pit or Grout Inspection by Date Final Inspection by Date ♦ u Addhiona0comments: t ❑ Stk 466-6781 ❑ Lodi. 369-3621 O Manteca 823-7104 ❑ Tracy 835-6385 ` Applicant - Returnn all Fbpies.ta:-frivironli idntal Heehh Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4, `� • 14..3 !. r t FRR�� UE AMOUNY AEMITTEcf CASH` ` RECEIVED 13Y -! DATE_,. . PERMIT'NO. - a.Eu'}24 MIN."sls