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Am5w �I�f 'y /1E.4YS APPLICATION FOR PERMIT SAN" JOAQUIN LOCAL.HEALTH. DISTRICT ' 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED T (Complete in.Tr'iplicate) Application is htmeby made to the San"Joaquin Local Health District for a permit to construct and/nOnstall the work herein described. This application is' inane in compliance with -an Joaquin Cnunry\Ordinance No,"5•i9 for sewalle or'�to IB62 for wetllpurnp and the Rules and Retiulauuns of the San Joaquin' Local livailh IN4111cl. L PAR CCA-S 1 Job Address 5 co 155+5r f L1NE JE��i4�� City MAC Y, Lot Size_ �Sn�lS p PM Owner's Name L4jigQR1_A 0/t r- 02CE Address .3, 00F/7 .SG//T 70r0 Phone Contractor tI f W Aelkk/�14_ _Address PA.-__Pa'�(. " �Q 1/IS7�iQ License N0.C-$7 d5"Y '(Phone ?16 4:V-N5-- TYPE OF WEt-LIPUMP: ;;NEW WELL ❑ WELL REPLACEMENT i.:l DESTRUCTION I.. PUMP INSTALLATION f3 SYSTEM-REPAIR'(_ OTHER 2" � r DISTANCE TO NEAREST: SEPTIC TANK - {!>•,/"c SEWER LINES" '�S DISPOSAL FLD. J ^ PROP. LINE',ZQ FOUNDATION 'tea r AGRICULTURE WELL (J- OTHER WELL I Mr g PITSIS MPS �` •�{ INTENDED USE TYPE OF WELL PROBLEM AREA C_4_NSTRUCTION SPECIFICATIONS 00k-IAIG S ii Industrial L7 Open Bottom Ci Manteca Dia. of'We'll Excavation IL2 - Dia. of Well Casing ` I i Domesiic/Private I_� Gravel Pack cefracy Type of Casing 7 Specdicatlons Public I-1 Other Il Delta Depth of Grout Seat Type of Grout hn{llunn ,PQ Approx. 0813111 l I Eastern" .5offacu Seal Inslailud bye mil A�'!��/G✓� _�.. Repair Work Done i' Type at Pump H"P. Stale Work Done A Wult Destruction l] Well DiamBlel SealingMaterial (top"50'1 !1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIAIADDITION I I DESTRUCTION 1 1 ANo septic system par mured it pullfic sewer is RI available within 200 1• Auff 92- 1 Installation will serve. Residence Commercial Other Number of living units: Number of bedrooms >' Character of soil le a depth of 3 feet: Water Tali(e"depth SEPTIC TANK ❑ Type/Mfg Capacity No. artments PKG. TREATMENT PLT. f_l Me nA Distance to nearest; Well Foundation ProRP 9.7 geny �j M M LEACHING LINE Cl No. $ Length of lines Total i q &r _ FILTER BED 1-1 Distance to nearest: Well Foundation g C-�Af or%. FAt . r 'U(lNry SEEPAGE PITS I 1 Depth Size ^' Number ^- ��j-�,�$_ SUMPS I_7 Distance to nearest: Well Foundation Property Line T 1Q/U DISPOSAL PONDS 171 1 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 Di§trict. Home owner or licensed agent's signature cartifies 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 of sub-contracting sirinature'. certifies the following: "I certify that in,the performance of the work for which this permit is issued, I shall employ parsons subject to workman's compensa- tion laws of California." The applicant must call all required inspections. C mpleta drawing on reverse side. Signed X _ Title: OG,S r Data: ZU 4 FOR DEPARTMENT USE ONLY �j r Application Accepted by Date" L Area 3✓•D + Pit or Grout Inspection by /' r z " Date 6.��'� Final Inspection by Data Additional Comments: 0 Slk 466-6781 Cl Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 835- 5 � 9 Applicant- Return all copies to: Environmental Health Permit/Service's 1601 E. Hazelton Ave., P.O, Box 2009, Stk., CA 95204 ' U FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY.' DATE PERMIT"NO. INFO CASH hq �j �� ) . ER 1324tREV.tin5r�g. ei 5'S�Tq .AFH 14-M" /,.