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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTONIAVE., STOCKTON, CA Telephone (209) 4664781 PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED ^' l.,,t _Tu* (Complete in Triplicate) Application is hereby made to the Sen Joaquin Local Health District foraJ. , I roads in compliance with San J oaquin County Ordinance No.549 for Permit to construct and/or install the work herein described.This application is I' Local Health District: sewage or No. 1882 forwell/pump and the Rules and Regulations of the San Joaquin p ' Job Address ��.>� -., , "Cry'. C; tip J ,,; r' ;y1. . . _ ,�L Lot Size--� PM I Owner's Name QVl Lf . , . - Address� _ - - _ Z Contractor - - - Phone Address N�'7`p�, �- t YP.EAF-.WELT/PUMP:--r--.- s— License No.All �72f Phonate NEW WELL❑ •WELL'REPLACEMENT"❑"'�^ LPU14P INSTALLATION ❑ DESTRUCTION'❑ - DISTANCE TO NEAREST;.1 SEPTIC TAAK SYSTEM REPAIR C1 OTHER ❑ SEWER LINES DISPOSAL FLD. f .FOUNDATION AGRICULTURE WELL PROP. LINE _ INTENDED USE +� / TYPE OF WELL AGRICULTURE OTHER WELL PITS/SUMPS ❑ Industrial �— �_ 'CONSTRUCTION SPECIFICATIONS ❑ Open Bottom ❑ Manteca D. of Well Excavation ❑Public k/Private/ ' ❑ Gravel Pack Dia. of Well Casio ❑ Trac ❑ Public f y Type of Casing } ,1 g /f ❑ Other � .p Delta Specifications - El Irrigation _Appro` Depth Depth of Grout Seaj fr' `(+ P ❑ Eastern Surface Seal Installed Type of Grout /I' Repair Work Doe ❑ iype of Pump Well peatructidn H.P. r F ,$teteyVork Done � ! ❑ Well DiamSfer Sealing Materiial•(top Fi0') ' Depth -'t�_ Filler Material (4100 ,50,),; i r, l TYPE OF;SEPTIC WORK: NEW INSTALLATIOfT� REPAIR/ADDITION ❑ r/ �1 1{ ST�RUj .I .4❑ 'I, -septic system ermitted d Ineta"71ati1on will it Residence f }A r,,y"'�:' available within fcet,) Dublic sewer jg C Commarcfal_ Other ^ tl,P _6j .'+ss..c. Nlim6ar of jiving units:_L Number of bedrooms_�_ • "j phare TA of soil to a depth of 3 feet i yy �,�y t�raw.l -1 SEPTIC TANK X Type/Mfg L ----,r Water table depth PKG. TREATMENT PLT.❑ r 'Capacity I: 0 No. Com (. pamnenta _r Distance.to nearest: Weibf� �'� Method of Disposal Or ) oundation l--property Line >� f t LEACHING LINE - '?9 '�, No. & Length of lines r FILTER BED ❑ Distance.o nearest: 7 1 Total jengfh'/size eL `Well�_ Foundation R,�/ I }-----�-Property Line ' SEEPAGE PITS ❑ Depth t r'7'gV Size SUMPS I "-"1Vum ❑ Distance�ta nearest: Well bar "DISPOSAL PONDS ❑ } Foundation ` Property Line I hereby certify that I hays prepared this application and that the work will be done in accordance with Sen Joaquin county ordinances, state laws, and Home owner or licensed agem's signature certifies the fo8owing: "I certify that in the empby any parson in gush manner as to bacorne sub'ect m wo parlbrmance of the work for which this cert8lee the}o8owjng:"1 certify that in the I dcmen's comtxsnsation laws`of Csliiomja."Contractors hiring or sub-contractrryit is ing signature mi tion lawa'of California•' performance of the work for which this permh is laeu�il;I shall employ persons subject to workmen's co The applicard must call I t`i-v_.1=1;5"r't"rt.Q � mpensa- d•irtl;pections. Complete drawing on reverse side. 'Signed Two: - ' Data: FOR DEPAR1TMENT'USE O LV Application Accepted by ^' ..• pc Pk or Grout Inepectlon by -..-P Date _ Date Final Inspecdory`bp" - Comments: Additional ata ❑ Stk 486-8781 .Lrxfi 3f21 — -�,•n .+ .f Applicant- Return all co ' ❑ Manteca 82&7104 vs�fl Tracy 83 pa>8 to: Erwironmemal Health Pertnk/Services.1601 E..Hazelton;Ava., P!0:-goz 2009,Stk., CA 95201 FEE AMOUNT DUE _T-'TTYr . INFO .AMOUNT REMITTED CK RECEIVED BY - CASH DATE PERMR'7i0, FH ibA W 1�Zd f � .