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1 �N f %W.41 APPLICATION FOR PERMITS , SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete 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 comphanco with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wetl/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �% �� 7 J Yl City S io4r bDn1 Lot Size f rPM !3� Owner's Name _ �,�.t'�'�I K^K Lp- 4 n, 'rte Address 90q, fie 10 4r„►La.C� �JYS Phone r Address e Contractor 69N 'it tftYrl �L_d License No. - �UL13V-3 Phone 11 -,2 9 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION L7 PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER §Z 5, k �`.,� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �� _ DISPOSAL FLO. — PROP. LINE --i FOUNDATION --�1� AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I 1 IndustrialL) Open Bottom U Manteca Dia. of Well Excavation 7.5 . +c Dia. of Well Casing I ) Domestic/Private LI Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public Other H5A f-I Delta epth of' rou ea! - -�--- Type of Grout G.e 1 I IniUarion �� Approx. Depth I I Eastern ear I by ,5 Repair Work Done I ) lap o��mp — H.P.HP _ _ State Work Don _ Wetf-Destruciion y'C Diameter '•�•J� _ Sealing Material (top 501 _ CP,,,,..t c•� `2� f fh.L-.�J��jBµ(k, ?CF406- Depth S$.D F1~ 30114 Filler Material (Below 50'I _- TYPE OF SFF'rtC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I !No septic system permitted if public sewer is 1 available within 200 feet, Installation wilt serve: Residence -_ Commercial_ Other Nurnber of living units Number of bedrooms Character of soil to a depth of 3 feet: Y� —_—_ Water table depth SEPTIC TANK I I Type/Mfg ._ _ Capacity _ .. No Compartments PKG TREATMENT PLT i ' Method of Disposal Distance to nearest: Well Foundation Property Line _— - LEACHING LINE I t No. & Length of lines Total lengthlsrre -- FILTER BED i I Distance to nearest: Well Foundation _ __— Property Lineµ__. SEE-PAGE PITS Depth _ Sire --- SUMPS Distance to nearest; Well Foundation Property Line DISPOSAL PONDS I heretry certify thdt I have prepared this application and that the work will be done: it, accordance with Sdn Joaquin county ordinances, state laws, and nrleS and re41ufa1011s of thn San Jnadwn LOcal Health Disin(A. Home owner or I c'unsod agent's si(}natures comities the following: "I certify that in the performance of the work for which this pe+mit is issued, I shall riot umpioy any person rn such manner as to hecorno subject tq workman's compensation laws of California.'- Contractor's hiring or sub-contracting signature candies she f011owrng: "I cortify that in rho performance of the work for which this permit is issued, I shalt employ persons subject to wwkman's compensa lion laws of Califomia." The applicant must call for all re used inspections. Complate drawing on reverse side- e •1 Signed X C�. :[ _ �`+ .__ Title �A (-S-- ",crr T j T - Date: d !f r FOR DEPARTMENT USE ONLY ApPlrea[eon Accepted by Date Pit or Grout lnspecsion by _ Date _- Final Inspection by Date / r Additional Comments: IXIStk (A Lodi 369-362! ❑ Manteca 823-7104 f.1 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 45201 440- FEE AMOUNT DUE AMOUNT R!_MITTED Y INFO CASH RECEIVED BY DATE PERMIT NO. *-