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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1,YEAR FROM DATE ISSUED iComplete in Triplicate? 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 lot sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address (o,b.' PAc rFre— ' AW^144f City S*C A' Lot Size PM Owner's Name 1�47faGR L �'D2o��►r ddress �� N` C/��r Phone R e� �7 Contractor SPE6720�1 rEXf'p�T/_U4ddres .Z- . r /lyelL 7R'r�-L�nse No.S�zLG� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL. REPLACEMENT ❑ DESTRUCTIONpt-E", PUMP INSTALLATfON O SYSTEM REPAIR ❑ Or °THEi1_Y)DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISP.GSA.V LD `� `I. =PRO .LINE FOUNDATION AGRICULTURE WELL OTHIFI.W1 ErL� PITS/SUMPS � INTENDED USE TYPE OF WELL PROBLEM AREA tEA CONSTRUCTION SPECfFJC_ATIONS ��t'S'tF<T J f f/ 01WAY ❑ Industrial ❑ Open Bottom C3 Manteca pia. of Well Excavation0i I n Dia. of WsII Casing ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing v{ �'Sp`e'ciiccaltions P1►L7Y4L.�+D I'I Public �C Other/e-AA"-`n Delta Depth of Grout Seal tl VIA rout I I Irrigation _-Approx. Depth t 1 Eastern Surface Seal Installed by Repair Work Done U Typelof Pump 'H.P. State Work Done_ WellDestruction ❑ Well Diameter eirm rf _ SealingWaterial (top 50'i/f WTje, Aie7ZAIO Lri`+'rlri+r_ 6 FAIII,JW .VF.-"4C Depth x �$' �` Filler Material leelow 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION I:l REPAIR/ADDITION f 1 DESTRUCTION I I INo septic system permitted it public sewer is r available within 200 feet.) Installation will serve: Residence:— Commercial_ Oiher Numberwof living units: Number-of bedrooms 1 Character of soil to a depth of 3 feet: Water table depth SEPTIC.TANK O Type/mfg :fir' Capacity No. Compartments PKG..,TRFATMENT PLT.D Method of Disposal Distance to'nearest:. Well lxaundation Property line ,I LEACHING,,UNE Y.:..0 No..B L.ertgth,of snes ` Total length/size FILTER BED z, CI Distance to nearest Wel! Foundation Property Line SEEPAGE.NTS. _ IL Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL POND 0- I hereby r 6MY,`ttiai. have prepared.this-application and,that the wor ill be done in accordance with San Joaquin county ordinances, state laws, and rules and regulat: rk bf the San Joaquin Local Health District., Horne owner,or)loan agerd's signature certifies the foflawing: "I certify that in the perfofrnancs of the work for which this permit is issued, 1 shall not employ any peraon in such manner as to become subject to workman's compensation taws of California."Contractors hiring or sub-contracting signature certifies tha.folloviring:_11 certify that in the performance of the work for which this permit is issued,I shall enpby Persons subject to workman's compensa- tion laws of.Cafifornia." The appl,caat fired'in I Complete drawing on reverse Sigma ^ € Title:AO/lv6> JtaGc1' �4 v r Date' -FOR DEPARTMEIUB!~iONLY �Applicatlon A a +13 t.� �y s Area .7 Ph.Of_Grnutprtriap ctiori by., Date - Final laspscoon by Date Additiona3 Cairirrtsnts3 a ' D.Stk 468,-878 Fey �, D Lodi_a 3t3�3MI - D Manteca 823 7104 ❑Tracy }- Applicant ,Return ad aopi*s tot Ertvlrortt»ertw,140"Paftlnit/Services,1f30hE.'Hamilton Ave.;P.O. Bas 7009, Stk., CA 95201 F4�y - FEE y AIMOt11tT,DUE rvAMOUNT REMIt"1ED RECEIVED BY Z.-:INFO DATE PERMIT'NO. ti -rt IRV.