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c j 1 APPLICATION FOR PERM;T SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON -WE., STOCKTON, CA Telephone (209) 466-6781 PFRPAIT EXPIRE£ ' YEAR FROM DATE ISSUED i (Complete in Tripli�atel Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descnbed.This appfication is made in compliance with San Joaquin Cn-imv Ordinance Nn.549 for sewage or No.1862 for well/pump and the Rules and Regulahuns of the San Joaquin Local Health District 3So 7- _ F yr Sod s�o�it>�� 1x z�s .lob Add,ess yy7 - -____ Dry. Lot Size PMOwner"s I�t4 .(L1� -- Address ` � "'� / - V'Irone.F.fi �.l1lt• ce.a ✓Aas.c 4 __ccu��,��,rs� C-7 QConuacloAddi,tssJ_C)4)� 7S/!l��/'Li�nseNo./��/ /✓ Phone TYPE OF WELL/PUMP: NEW WELL ISY WELL REPLACEMENT LI GESTRUCTION L _ PUMP INSTALLATION :rr SYSTEM REPAIR Cl OTHER ❑ DISTANCE TO NEAREST. SEPTIC TANK SEWEF LINES _ DISPOSAL FLD. PROP. LINE f FOUNDATION AGRICULTURE WELL OTf.ER WELL PITS/SUA:PS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS / y U Industrial ❑Open Bottom Ci Manteca Dia.of Well Escavati�,n Dia.of Well Casing (� fl Domestic/Private Gavel Pack I 1 Tracy Type of Casing/C- Spec[acations 1P'�ublic Cl Other i I Delta :lepth of Grout Seat _14 Type of Groul"e�71,�,"7e - I I Irrylation ZVUApprox. Depth I I Eastern Sur race Seal Install,d by r w' Repa.r W vk Done I.) Type of Pump -Sorg__ H.P.__j _ State Work Dont_ r Weil Destruction B— Wcll Diamet r Sealing Material Itop 501 Depth _ Filler Material(Bek iw 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I Rr;'AlWADDITION I I DESTRUCTION 111No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence__ Commercial__ Other Number of living units: Nur.tber of bedrooms Character of sol to a depth of 3 feet _._ Water table depth SEPTIC TANK O Type/Mfq _ _ Capacity No.Compartrneots PKG. 7REATMENT PLT.❑ Method of Disposal _ r Distance to nearest: Well Foundation._ Property Line _ LEACHING LINE ❑ No.&Length of lines Total length/tire-- FILTER RED CI Distance to nearest: Well Foundation ___ Property Line SEEPAT;E PITS I I Depth Si_e_-_ __ Number_ SUMPS I I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C I I hereby certify that 1 have prepared this application a.id that the work wi I be done in accordance with San Joaquin county ordinances,state lsws,and rules and regulations of the San Joaquin Local Health District. Home owner or licensed a eni's sirnatuM certifies the followirg:"I certify that in the porformance of the work for wfiich this permit is issued.I shelf not umploy any person uch nner as to become subiect w workman's compensation laws of California'•Contractor's hiring or tub contracting signature certifies the foil mg:"I cert y that in the performance of ly work fnr which this permit is issued,I shall employ persons subject to workman's compenu- '� tion laws of lilor ` Thv applic t 1 all requi pl- rSg on7eXerse side. yyJ Signed T'Je:��S.�L/ � Date: /// R DEPARTMENT USE ONLY Application Accepted by e-�'� '�-1�./�/��-=- _ Cate ` Ares ��q9 _ Pit or Grout Inspection by e � � UJ.nuf �� Final Inspection by `, ei< Dote I / Addiuonel Comments: p�l Cll[�-�!��Yl•�-�s ��yy''r'` t'F' /��'�"«} "' �/ /.f ••</ ❑Stk 466-6781 ❑ Lodi 369.3621 n Manteca 82MI04 O Tracy 835.638.5 ow Apllicent-Return all copies to: Environmental Hoalth Permit/Services 1601 E. He. It Ave., P.O. Bos 2004, 511'.,CA%"201 c>CYY1 CK r. INFO MOl1NT DUE AMOUNT REMITTED CASH RECEIVED BY DAT(/E��'� j11111,51yNO. .E FH tNIEl. 1 4f H 4-]e s � / r