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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTQN AV,E.,'STOCKTON, CA "Telephone 121 466 6781 t� PERMIT EXPIRES 1 YEAR FROM+DATE ISSUEDy�L2Y6GGal�`Oh/ (Complete in Triplicate) ''• Application la hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the Sen Joaquin Local Health District. Job Address Mrd_ .14 4Jq'r/g,je A.Je 2Y1 P 5 City (-MIDEiJ Lot Size PM . Owners Name L-ADEN 140b 6WAgiL _Address /.2d 144U I-, /Vjly S;iL',r,l Phone Contractor 61-0111`20 6• WMD Address_&&.0 A,/ " iAA1 License No. 42s.r 7G Phone L `3 TYPE,OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ e l,1 PUMP-INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE •- w r----FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE I'1 .i TOPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial °` I ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/trysts ❑ Gravel Padc ❑ Tracy Type of Casing Speoi kation, O Public ❑ Other 4 ❑ Delta Depth of Grout.Seal Type of Grout ❑ Irrigation :',_Apprbx.'Depth ❑ Eastern Surface Seel Installed by Repair Work Done r ❑ 'Type of-pump H.p. State Work Done Well Aestruction.� I O Well Diameter Sealing Material (top 5011 1: !' Oepth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/AUDITION ❑ DESTRUCTION ❑ (No septic system permitted H public sewer is IV available within 200 feet.) Il Installation will served Residence_ Commercial v Other (LJ Number of lying units: =Number of bedrooms Character of 54i1 to a depthpf 3 feet:—_L1rY-f_P9- 1 Water table depth rfSEPTIC TANK ne,r Type/Mfg 0,0 - SRN/6 c Capacity �7.3Q � No. Compartments PKG. TREATMENifP& ❑ Method of Disposal Distance to nearest: Well 3 oD r Foundation Property Line �Y-X-01,0 LEACHING.LINt k' No. & Length of lines 2--/ OO Total length/size y4110 rX Z N FILTER BEDY' ❑ Distance to nearest: WAII—�3�f"J.'';Foundation ^ Property Line SEEPAGE PTS M Depth f Or Size 14V Foundation r Number 'SUMPS -illDi O stance to nearest: Well� Foundation Property Line DISPOSAL.PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws; 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 performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify,that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for.all ulnad Inspec- s. Complete drawing on reverse side. Signed __ - Title: Date: •'? FOR DEPART ENT USE ONLY ` Date _� / - Qt Area D� CQ Appli�tion.Accepted by � ^ `C. Plt or Grout Inepectibn by Dete Final Inspection by rii'''" n r - Additional Comments: ❑ Stk. 486.6781 .s ❑ Lodi 369-3821 ❑ Manteca 8237104 ❑ Tracy 835463811 Applicant ReWm i all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,-Stk., CA 95201 IN AMOUNT DUE AMOUNT REMITTED CACKSH RECENED ey DATE PERMIT`NO. +8113211REV.1/eel �