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A APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 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/on install the work MreMt described.This sppacatlon s made in Compliance with San Joaquin County Ordinance No.549 for sswegs or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District tt ^_ ^ rL ` �[ Job Address _1 i-w DIS L-__AC i City —40&L— Lot Sue___— PM -- Owner's Name A��\, � t'CAddress - �.�Q _ Cpalzaf4er _. 1 Adrtrr s^ --------------- __Ucense No. TYPE OF WELL/PUMP: NEW WELL V WELL REPLACEMENT I I DESTRUCTION I I —� PUMP INSTALLATION ' SYSTEM REPAIR LI OTHER [I w DISTANCE TO NEAREST SEPTIC TANK G�.�t_-- SEWEn LINES _L2 — DISPOSAL FLO.—__ PROP. LINE _ N FOUNDATION __ AGRICULTURE WELL OTHER WELL_�—___ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS — � Industrial I 'O Bottom Manteca Dia. o1 Wall Excavation L Dia.01 WM Caskq -- o'"tic/Pterste Gravel Pack Tracy Type of Casing- Spiseificaliors Public ^i �1 Other Delta Depth of Grout Seal Type of Grout— [rogation 151 Approx. Depth Eastern Surface Seal Installed by_---- — — Repair Work Dorm Type of Pump N.P. -_—_ State Work Done __--__— _—.— Weal Destruction Well Diameter Sealing Material[top 50'1 _ -----_-- —----- Deplh Filler Material[Below 50'1 ... ----------—- -- — - -- TYPE OF SEPTIC WORK NEW INSTA LATION REPAIR/ADDITION i DESTRUCTION I 1 INo septic system per"~if public sewer is available within 200 feet.) Installation will serve RsK elence Commercial _ Other Number of Irving units Number of bedrooms �_ __ :It Character of soil to a depth of 3 feet - -. -- - --- /q^ _200_.._ Water table depth ----- _ - SEPTIC TANK I,,"' G Type Mfq _ _ .. _—___ —_ peelh_( -.44 Pio Compor",nonts -- PKG. TREATMENT PLT , Method of nDisposal Distance to nosiestWell —. Foundation____ Property L. �l; LEACHING LINE V"No. A Length of bites — FILTER BED i ' Distance to nearest Well-. _. Foundation __-_-- Property Lill- - / .77 —r--— — Numttsr —SEEPAGE PITS t-'Depth �,? . _ Sire -r---- i SUMPS Distance to nearest Well � FoundationProperty line_ DISPOSAL PONDS I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state 4ws, and rules and regulations of the San Joaquin local Health District. Home owner or licensed agent's signature certifies the following: "I certify that In the parforrtwoce of the work for which this pat &'I H issued. I aha*not employ any person in such manner as to t,ecomn subject to workman's compensation laws of Cakfornia."Contractors hiring or sub•contraetrng sigrvtun certifies the following "I cen.fy that it,the trformance of the work nor wi�ich this permit is issued.1 shall employ persons subject to workman's compensa- tion laws of California" The applicant m call for all requnrM inspections Complete drawing on reverse side l L�' Dau: _-- Siprted x �. fl,.f/.� � _i•• /^••_�.;_ Titin --- ll FOR DEPARTMENT USE ONLY Apptruuon Accepted by - C l'. '/ •. ' r Oi to �4-- Ane Pit or Grout Inspection by s. •/ Date e.� .,l: Fn,al Inspection by LLG..1(4//y_�...(,.(�r.-- Bale s+- Additional Comments -- Stk 466 6781 Lod 359 3621 Manteca 823 7104 i'Tracy B3 -SM Appl"el . Return all copies io Environmental Health Pat fell Services IWI E. Haretion Aver., P.O. Box 2008, Stk., CA 96201 FEE AM(`uNT Out AMOUNT;iwrtEO CASH RECEIVED By DATE PERMIT NO INFO -71 TT- L.--" -•--- - -Z 7-5 fie,r)rl •1•�� -"-