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.477�/f✓ RAY ArAys u APPLICATION=FOR'PERMIT v SAN..JOAQUIN LOCAL HEALTH -DISTRICT 1601 E. HAZEL T ON DAVE., STOCKTON.; CA Telephone (209).466-678t PERMIT EXPIRES 1-YEAR FROM DATE ISSUED t lComplete..in Triplicate) Application is hereby made to the San'Joaquin local Health District fof a permit to construct and/or install the work herein described. This application-is- made in compliance with n Joaquin County Ordinance No. 549 far sewage or No. 1862 for well/:pump and the Rules and Regulations of the San Joaquin Local Health District. ��jl Job Address /tQ'J 7rL•�A�� i�� City Lot Size . J�XIS�U PM 44 Owner's Name aQRL1_ 0 4 IfCio ?: Address 30600 6) AX,40162 _ -5'aL77--r7Cra_ Phone Contractor V ff W _2W141-/414� Address P 136.x` / •Po 1//.STA License No.C-57 651-7S6Phone 9I6 d3/w% e TYPE OF WELL/PUMP: NEW WELL ❑-' WELL REPLACEMENT F1 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Bo DISTANCE TO NEAREST: SEPTIC TANK '` r •C SEWER LINES DISPOSAL FLD. ^; e PROP. LINE 1Q_ FOUNDATION ' AGRICULTURE�WELL a•f�+° �OTHER.WELL , �+/Ie PITS/SUMPS 'k INTENDED USE TYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIFICATIONS 00`01,v6s i Industrial ❑ Open Bottom' - C Manteca Dia- of Well Excavation ld Dia. of Well Casing_ "— i Domestic/Private C-2 Gravel Pack C11racy Type,of Casing- Specifications r Public 1_1 Other i Delta Depth of Giout Seal Type of Grout&ZAb+lrr79-C E'r16 A.r' ;Fri(,)auon O_ Approx. Depth P Eastern Surface Seal Installud by'- 1L *-AJ DPI IAA_/A/G. _ Repair Work Done ❑ Type of Pump H.P- State Work Done'W NR 'Nell Destruction LC Well Diameter 'Sealing.Material Itop 50'1 . Depth` Filler Material (Below 50'). TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted.if public sewer is ( , I available within 200 feet.! 1�} r Installation will serve: Residence_' Commercial_ Other Number ot.living units: Number of bedrooms Character of soil to-a.depth of.;3 feet: Water table'depth SEPTIC TANK ❑ Type/Mfg Capacity No: artments ' WA PKG. TREATMENT PLT. O Me o I Distance to nearest: Well Foundation Propertv � .,({� LEACHING LINE ❑ No. & Length of lines Total l /Mize. �` rte,Ali ... FILTER BED ❑ Distance'to nearest: Well Foundation _ EN1q� �Q — . ME t r f� 1 i` SEEPAGE PITS i I Depth Size. Number SUMPS Ll Distance to nearest: Well 'Foundation Property LinefQv DISPOSAL PONDS 0 I hereby certify that I have prepared this application and that the work will.be'don.a in.accordance with San Joaquin county ordinances, state laws, 'and rules and regulations of the San�Joapuin 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, 1 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 W6rk-for which this permit is.issued, I§hail employ persons subject to workman's compensa- tion laws of California.' .." The applicant must call. all required inspections. C mplete.drawing-on'reeverse side. Signed X Title: Date: 9 'Do JL ove, ,FOR DEPARTtMENT USE ONLY T. Application Accepted by Date Area Pit or Grout Inspection by- Date Final Inspection:by Date '_rte Additional Comments: �r�SVTL SOI ( Dr(� 5COMM ._:gni• ❑ Stk' 466-6781 El Lodi '.369-3621 ❑ Manteca 823-71.04 ❑ Tracy .835-638— Applicant- Return all copies to:.Environmental.Health Permit/Services 1601 f: Hazelton Av'e.,Q.P.O. Box 2609, Stk., CA 9 FEE AMOUNT DUE AMOUNT REMITTED , : ASH RECEIVED;BY. DATE PERMIT ND. INJJfJJO C r r l + EM F3-24{DEV-rimer o. / �U� EH 14-28 G VVV ✓✓✓ L ... 1