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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PERI" N0, 1601 E. HAZELTON AVE., STOCKTON. CA Telephone (209) 466-6781 DATE ISSUED =�F=- PERMIT EXPIRES 1 YEAR FROM OATS ISSUED -~ Complete in Triplicate)for a l the Application is herehiicatiotois)ea a`ninoaquir.Locistrict Healtn'DJOaquin CountypOrdinancecNo. 549tfor dsewage sorl o. 1862rfor ewell/pump r coplian ith San described. This app and the Rules and RegulatOns of the San Joaquin Local Healtn district. - C f- V� ��Subdivision Nark �E}dd} � Phone Job Address �C�F � Address Phone — rn� -Owner's Name n d i._.e y,��. License Ne- Contractor's Name 1 TYPE OF WELL/PUMP WORK:. NEW�WELL ❑ WELL REPLACEMENT DESTRUCTION SYSTEM-REPAIR' L OTHER U - i PUMP INSTALLATION DISPOSAL FLD. PROP. LINE t SEWER LINES WELL PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL — FOUNDATION 1NTENdED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Manteca-"•�• Well,Excavati6h T' Industrial r-1 Open Bottom Domestic/Private ❑Gravel Pack ❑Tracy Dia.' of well Casing ❑Public []other ❑Delta Type of Casing Irrigation Approx. ❑Eastern Specifications Depth Depth of Grout Seal ! ❑Cathodic Protection . ❑Geophysical Type Of Grout ❑Other Surface Seal Installed by _ H.P. State Work Done ~ Type - —---- , ,C Repair Work Done ❑ Ype of Pump Sealing Material (top 50' - �•1 Well Destruction C Weil Diameter ) x Filler Material (Below 50' Depth ) — available within 200 feet.) TYPE OF SfPT:C WORK: NEW INSTALLATION f7REPAIR/ADOIT?ON (No septic tank or seepage pit permitted if public-sewer,is Installation will serve: Residence)L. Commercial Other rooms —3' Lot size Number of living units: _ '� Number of beda , Wa-ter table depth Character of soil to a depth of 3 feet: dtc�._ Capacity_—__� NO*Compartments t SEPTIC TANK Type/Mfg 1 ca do t �+ietfiod of disposal — p Y PRG. TREATMENT PLT, 1 TyWMfg ' - Property Line SEWAGE SYSTEM Distance to nearest; Well 1*dEFoundation DESTRUCTION Total length LEACHING -� l-4- ;40, &`Length of lines �+' �` ( LEACHING LINE �.� Foundation 16 — Property.Line FILTER BED Distance to nearest: Well _ 3 0 , ��-- 1( Size Number SEEPAGE PITS —__— -.:Depth4--'---�' r Property Line ❑ Foundation SUMPS Distance to nearest: Well DISPOSAL PONOS [�_ have I j !prepared this application and that the work will be done in accordance with San Joaquin county ? hereby certify that P Pa f Ordinances, state laws, and rules and regulations of the San Joaquin Local Health district:' Home owner or licensed agent's si,nature certifies the followinq:- 'T certify that in the Per of the work for which this permit is issued, I shall notemploy person i such manneres the asllovr_ing is cccm ertifyubjact ttratrin thecompensation per ormdnce ofwthefworkifornwhich Contractor's hiring o 1 a rsons subject to workman's compensation laws of California." this permit issued, .1 _i �w The applic t us call or a re uire spec tions. Complete drawin on rei rs ��— Date, ii •Title: `-�. Sign .X 466-6781 t -NT uS£ ONLY Area Stk t '�' -- ❑ Lodi369-3621 Application Acceptea"bY Additional Comments: date — _ - nteca 8.3 Pit or Grout Inspection y _ ,:��C f'"i Tracy`..--835-6385 _ Date _ r spection by - Return all copieslto: Environmer.tai health Permit/Services 160 E. Hazelton ton v'•� P 0• Box 2009, St k., CA 95201 Final in DATE PERMIT NO. AMOUNT REMITTED RECEIVED BY _1 i FEE BASE AMAUN7 di E L4 �51 L E � INFO , 'IR 101!32 600 i EH 13-2`4 REV. 10182 ' `C "Tl� 14-26