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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA _ Telephone 1209) 488.6781 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 Mein described. This application is made in compkance with San Joaquin County OFdewnce No.549 for sewage or No.1882 for well/pump and the Ruin and Regulations of ttw San Joaquin Local Health Distnett. `j'ae1..] , ,., ��/�'a .'d'1 //:Cr Citv'• .� LM Sba PM /?�•- Job Address _ - Owner's Name �1,�`/sld - Adrraas �� ! J" W LK)�• -at.f'lrlfepwzt, Phone Contracts -le Address' _/�rd'_{ W06AA�License No. 7'Z' Phone 3AAyZ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL _ PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial`•,� Y{+ OApen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wall Calling Domestic/Private G.ravel Pack ❑ Tracy Type of Casing Six"Caft" O Publicj3er—^t �"---O-Oehta "POaPth-of Grout Seal- 11 eal "'' - �TYCa pTGrsA ❑ Irrigation � 'Om;woY. Depth ❑ Eastern Surface Seal Installed by r Repair Work Done ❑ Type of Pump '" H.P. State Work/,Pone 4- t Well Destruction' ❑ Weal Diameter' -Sealing Material (top 50') _V. Qepth Filler Material(Below 50') 'i TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION❑ INo septic system permitted if public sewer 1 1 i't ./ available within ZOO feet)i Installation will server Residence Commercial v Other �y i Number of living units:_ (Number coo _ T Character of soil to a depth of 9 feet:. Water.table deem SEPTIC TANK �, [I Tye/Mfg .It pecity ?nU No. Compartments Z Method of Di1 PKG. TREATMENT PLT.C1n S - / Os7o� t \ Distande to nearest: Well — Fourtdetilin �� Property Line _— LEACHING LINE 2"No.S iengm'at lines r . FILTER BED Cl Distance tonearest: Weal - Foundatlon1i O' Property Imo ry f _ ) Number SEEPAGE PITS Cl Depth ..� -5� 1 ' /Or ^ rty Lire , � SUMPS 1,''OWarlps m�naarwc WON Fq�atdadbn _ Pr_ope . ^^ 7 t DISPOSAL PONOS n Z: l`. Its 1 hereby certify that I have prepared this application and that the wall sill be data In accordance with San Joaquin county,ordinances, state laws.and rules and regulatidns of the San Joaquin Local Health District. 'f which this permit is issued, I shill not Home Owner or Hcermd agent's signature certifies the following: 111 care��1tl�W in firers peirf men nce of me work for of firma„Contractors hiring orsub-contracting signature employ any person in such ma"r as to become subject to workitan'f m�rpMwYonAaNa L certifies the following:;'I.catlfy that In',the performance of the work for which Thos Pamth is Issued,I shall employ persons subject to workman's COmPGnSa- 'tion laws of CaIRO14111SP The applicant must-Calf for BYrequired hspections. Complete drawing on ravines side.l jb :.zt��y Signed Tale: /1C�,pG/ Date: g •-•f'!�r - FOR DEPARTMENT USE ONLY r y 'Wb Aree Application Accepted by. i _ .brie yfii'i paahiwt W U QA� Dila�� Pit or Grout Inspection by I Additional Comments: ❑TT� � _ ❑ Stk 4866781 ❑ Lodi 389.3321 ❑ Mnt aeca OZ1.7104_.f. 1 racy Applicant - Return a8 copies to: Envirdimeefdo Heat PerrniNServi ift U01 E.�Ha rwArm Ava., P.O. am 2009, Stk., CA 85201 L T ' 1 AMOUNT DUE _ AMOUNT REMITTED CASH KRECENED aYT'V DATE PERMIY NO- j , 7 -1433 .EX t3aE WO 1REV.v a al O, EH t4�