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�-- APPLICATION FOR PERMIT 1� — 0 Id`s / SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 / PERMIT EXPIRES 1 YEAR FROM DATE ISSUED rJ (Complete in Triplicate) r Application is 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 Rules and Regulations of the San Joaquin Local Health District. city X�C- Lot Size_L4-2 �— PM_— — _— - Job Address —J=— r _ _ / +-, �_ S 1♦ 1 5 � w_�15-RS--- Address _1 -7 Phone _-- Owner's Name _:s_ a1v'�. P6�,50 L_" CS'7-280310 phone�" �� 1 1k O-. . License No.-:� t 1p.�Rvb Address_ Contractor L� - NEW WELLK WELL REPLACEMENT C. 1 DESTRUCTION Fi, f 10. er�,1J4 Wcu TYPE OF WELL/1 _. - SYSTEM REPAIR OTHER PUMP INSTALLATION G DIShOSACFLDD �lPROVLINE^_ 'SEWER LINES — PITS/SUMPS — DISTANCE TO NEAREST: SEPTIC TANK._ -- I OTHER WELL—. — — FOUNDATION AGRICULTURE WELL -- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS c-� Dia. of Well Casing 2 t►D�l 0 Open Bottom C Manteca Dia. of Well Excavation_-- 0 Industrial Type of Ca,4"V rt�'=— Specifications Dgsff�e�%1Private Gravel Pack ❑ Tracy v , r• ��$—� Type of Grout� . r I CI Oth�r rl Delta Depth of Giout Seal _ I' Public t R 'fro C� r Surface Seal Installed by_AEN-- � Ir6gatior � 1rgt7Apnrox. Depth I ' Eastern �✓* State Work Done _— of Pump H.P. — -- ~ Repair Work Done J Tye Sealing Material (top 501 Well Destruction LJ Well Diameter -- Depth _ Filler Material I8elow,501 -- TYPE OF SEPTIC WORK:-NEW INSTAI 1A710N t 1 REPAIR/ADDITION l i STRUCTION I septic systern thin 200 feet .) it public sewer � rs — - 1 Installati+n will serve: Residence_� Other Commercial —_ � 1 "Number of living units::_�l Number of bedrooms— — Water table depth Character of soil to a depth of 3 teat: Capacity_ No-'Con1153rtments'7- SEPTIC TANK 0 Type/Mfg — Method of Disposal PKG. TREATMENT PLT. 0 , - Property Line 1 Foundation _' t 1 Distance to nearest: Well _ — ,-_ t •.�-..0 r - I -- _ Total length/size 1 1 o&! t❑; NLength of lines - ► t LEACHING LINE Foundation ` Property Line FILTER BED , C Distance to nearest: Well — t ► , _Size J Number SEEPAGE PITS i Depth r Property.Line - Foundation —. SUMPS. L' Distance to nearest: Well — r ` F1,-3(0 DISPOSAL'PONDS� 7. ared this a lication and that the work will be done in accordance with San Joaquin^Tounty nidi,antes, state laws, and. I lwretiy certify that I have'prep pP rules and regulations of the San Joaquin Local Health District. Z work for this Home owner or licensed su agent'smansign torbecome subject following workman'sirtcompensation lify that in the awsofCalifornia.—Contractor's lhiring orr sub-cont its t act nglsignlaturre employ any person, certifies the following: "I certify that in the per rmance of k for which t "s perjnit is iss ,l shall employ perso�object to worms an s�mpen;� � tion laws of California." b/ 7- The applicant must call for all requin inspections. Complete drawing on reverse side. _ / — Date: Title: — — Signed X FOR PARTMENT USE ONLY �_ �_ Area n� O Date (J Application Accepted by — ¢ Z iy-r � _S,7 Pit or Grout Inspection by Date t1,-3-//��- a inaI in, by — Date Additional Comments: r Ll Stk 466-6781 Lodi '369 3621 p Manteca Services O Tracy 635-6385 Applicant - Re urn all copies to: En nment,3ldi�alth Permit Services 1 � Haz�n Ave., P.O. a 2009 Stk , CA 95201 Q1.�uCy '� 3 S pie-1 Y 1RECEIVED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED INFO b . EH 1324 tREV.r%K51 EH 14 20 Z