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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 466.6781 PERMIT EXPIRES t YEAR FROM DATE ISSUED (Complete in Triplicate) Application is IreraW media to the San Joaquin Local Health District for a permit to construct and/or instal the work heron described.This applicetion b media in compliance wth San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rubs and Regulations of the San Joaquin Local Health District. p �� /� Job Addross —60— IA Cittv4d 'd�/3ls.r_ Lot Six _jFAdr--Uf-*M p c '^1 /f JJ�� t.«,r�c Y �3 it -eneisN V�J KI..E'.R-�.as_ Address es 6L7 �/a L` / ^�zif Contract e�/�' 040 Address _ _License No. .2-7g�o^e OS TYPE OF WELL/PUMP: NEW WELL iJ WELL REPLACEMENT 1 : DESTRUCTION I I PUMP INSTALLATION t: SYSTEM REPAIR Il OTHER C' 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 ❑IndusaNM ' Open Bottom Ll Manteca Dia. of Well Excavation - Dia.of Wall Casing 11 Dormseft/Prrvare i Gravel Pack 11 Tracy Type of Casing-_ _____ Specifications LJ I l Public Other (1 Delta Depth of Grout Seel _. _— Type of Grout f'. INigstion _ Approx. Depth I i Eastern Surface Seal trial~by Raw Work Done I Type or Pump —. H.P. Stab Work Done Well Destruction ' Well Diameter Sealing Material Itop WI ------- ` I Depth_ Filler Material IBe '1 TYPE OF SEPTIC WORK NEW fNSTA!I ATION it REPAIR/ DITION 1 DESTRUCTION 1 I INo sept-.system permitted if public sewer or J available within 200 Ifjet.l Imtaaatbn will serve: Residence __ Commncuil-X Other �-it L��•y�t��'��sj. Number of eying win "60' Number of bschocens_I&—. / (� Chwalctn of two to a depth of J feet: _ ______. _ - -__ _Water table depth SEPTIC TANK I Type/Mfg _ ___ _ Capacity _ - No. Compartment; — PKG. TREATMENT PLT.I Method of Disposal _ Distanw to nesresf: Wee -._ Foundation - _ Property Line LEACHING LINE i No. a Length of limit _ LLS`. - .. . __ Total length/airs__yam FILTER RED I , Distance to nearest: Wd1 Foundation _.. _. _ Property Lim SEEPAGE PRS D' Depth Number. SUMPS Distance to nearer: Welt -_ ___ Foundation __-_— Praptty Line DISPOSAL PONDS 1 hereby certity,that I have p,epared th•t application and that the work yell be done in accordance with San Joaquin county ordinances, state laws. and rubs and regulations nr the San Joaquin Local Health Draft". Home owner or licensed spent s signature onehfiea the following. "I certify that in the performoi.ce of the work for which this permit is issued, I shall not employ any Person in such manner as to bscoma sutljacI to wwkmsn's comwrnetion Jews of CaMOM11-Connsctor's hiring or suDcomrsctbg&"lure wadies the foaoyed : "I comfy that In the performance of the work for winch this Permit Is issued.I shall employ motion$subject to workman's cmiprmsa Pont laws of California." The applicant call cell for all Imin/s'p�ection, Complete dravving lir.reverse side Signed K �a7':71��-ZY -K •�.L Tnki -'- Dsta. FOR DEPARTMENT USE ONLY Q Application Accepted by r' - Dale / - `r 6._. Arras �/ c Lr Pd a Grout Inspection ler L111`4 —6 1 Os1e �'" Fine; Inspection by _ ��:r �� Data 7-254654 Additional Commenn - Sts, 4F14761 LM- 3R9-621 - - -'-' Matters 6277104 Trecr 83tr6395 -�- - Applleant Flouu' nwr m all cop+s tc Eomeamal 1va Health Ilii Seencre, 1601 E minne eve, P O Bos 2006. SIL, CA 95201 p �= J' ' 1 .fa AMOUNT-00E- AMOUNT 11EMit?ED2 _ I _ I Rf.vto sy part — RMi/ NO tNrO - I} fly