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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {249) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1CompleW in T(plicate} Application is hereby made to the San Joaquin L w-al Health District for a permit to construct andi or install the work herein described.This application is made in compliance with San Joaquln County Ordinance No.549 for sewage or No. I SU for well pump Ano the Rules and Regulations of the San Joaquin Local Health District. w Job Address 3s• 'S/ '•-,5 f7¢+y _. city . L.at Size ,!_f ---- PM ---------- Owner's Name, *' �T�.� Address l.3 / /.rlGr�f_,ti Phone GJS- L.conse No. ` y Phone TYRE OF WELLPUMP. Y NEW WELL L] WELL REPLACEMENT DESTRUCTION C] PUMP INSTALLATION ❑ SYSTEM REPAIR 11 OTHER E �'� vV DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE —__-- e FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS va INTENDED USE- TYPE OF WELL PROBLEMAREA CON STRUCTION.,SPECIRCATIONS # b� U Industrial 1-1 Open Bottom Manteca Dia. of Well Excavation � Dia. of Well Casing U Domestic/Private = Gravel Pack ❑ Tracy Type FofCasingSpecHcatlans i Public 4; E Other IJ Delta .�Depth of Grout Seal _._-_- ..._ Type of Grout 1'J Irrigation —Approx. Depth ❑ Eastefri", Surface Seal Installed by Repair Work Done 'O Type of Pump f H.P- State-Wofk Done # r- Well Destruction L Welt Diarre;er J Sealing Material itop 50'l I� Depth Fillor Materid,"Below 56 t TYPE OF SEPTIC WORK- NEW INSTALLATION REPAIR?ADDITION D DESTRUCTION C (No sefstic system peFMtted if public rerwer's available within 200 feet-0 Installation will servo Residence [� Commercla: — Other__ Nurnber of living units: _� Number of bedrooms ' Character of soil to a depth of 3 feet: t Wa er,table depih'r �I f SEPTIC TANK U Type/Mfg ► r G� 'Capacity 12&c-' �+,� No. Compartments PKG• TREATMENT PL•T. =1 Me:hild of Disposal r DiTtance'to rwafesT: Well /GG F'ou'ndation +�r� Ptope-ty Lin /G LEACHING LANE ❑ No. A Length of Imes � /�T,CIAI-length?sizr � �,�/►U�r�'� FILTER BED I Distance to nearest - Well m!n Foundation f "-r_.L__ Propairy L ' ! j - -_- SEEPAGE PITS 10' SEEPAGE C Depth } Size Number SUMPS I' Distance to neaiest: Well Foundation Property Line I t DISPOSAL PONDS „ 17-- I I I hereby certify that I.have prepared this appFcatior.and that the work will be done in accordenceli— tan Joaquin coultty ordinances,'state laws, and rules and regulations of the San Joaquin Local Health District. _,%.% I Home owner or licensed agent's signature certifies the following,•Y ce'tify tha li; t performance of th work for whi h this permit is issued, I snall not employ any person in such manner as to become subject-.to workman's compensatlon,lav�s of-Cal:fomia."C6niraemrc hiring or sub-contracting Cgnature certific,s the fulk)wing:"I carnf Fiat in rhe perf�rnance of the work for which this permit is issued, I shall employ persons subioct to workrrwn's corn pen4a- tion leas of Calif The applicant e•Ca 9�11 r in �P?7eledlrarwing on reverse side.Signed • T tle t�Gli K/` - Date: / FOR DEPARTMENT USE ONLY /pyi Appiicatan Accepted by F Date ^v +I Area ' } Pit or Grout Inspection by Date Final Inspection by Oaio Additional Comments: ` `\. . ,•n Stk 466.6781 0 Lodi 38.9-3627 ❑ Manteca 6223-7204 ❑ Tracy 835,,GM Applicant- Return all copies to: Environmental Heatttt Permit/,Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 96X1 • 'i FUE i INFO AMOUNT r3UE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. EH 17-74 rRFv. IWM) -lGt"}'.. �� — tt �'��•!.� FH I ti