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APPLICATION FOR PERMIT .' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE,, STOCKTON, CA Telephone (208) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hetaby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is wade in compiianco with San Joaquin County Ordinance No.549 for sewage or No, 1862 lot weilipump and the Rules and Regulations of the San Joaquin Locale Health Dislrict. Job Address � d ---___ 1 e _ — City_` _� Lot Sire PM Owner's Name . !_�t G 577 2= Address z !_L` e Phone _..1 Contractor �� .1 wit✓fY Addiess License No;2z r Phone eJ6-. 2tr50— TYPES OF WELLIPUMP: NEW WELL Ll WELL REPLACFMFNT f'i DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR 0 OTHER LJ - DISTANCE TO NEAREST: SEPTIC TANK SEINER LINES ............._.._....._ .—_ DISPOSAL FLD.__._._ .._ PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL..........._..,_...._. PITS/SUMPS _ ___..._..__....�. ..... ..___.. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 171 Incustriai 0 Open Bottom 1: Manteca Dia. of Well Excavation_ Dia.of Well Casing ..___.. _ _ ....... 0 Domestic/Private 1;travel Pack r:. Tracy Type o1 Specifications ; I l Public a1:1 Other i.l Delta Depth of Grant Seal _ Type of Grout I I lr+;dation ---_.__ _Approx. Depth ....i i.Eastvrn..__.—_�Surfaca`teal installad.by__..__.. ._ Rep6ir Work Done L Type of.Pump H,P, State Work Done_......._._ Weft Destruction 0 Well Diameter Sealing Matt'641,110p 601 --- Depth fillet Material f akyw 50 J TYPE OF SEPTIC WORK. NEW INSTALLATION .REPAIR 1ADD(TION I ; DESTRUCTION I i (No septic system permitted if public sewer is available within 2W feet.) In!s Nation will serve- YResideenct if-,cam rcAa Other Number of living units: _-1 Number,of bed?ot>esv�S� y�� .:,...._.__ ' Charactpr of soil to a depth of 3 feet: y im+ .... ..._... _.___•�-._. ,w... . _...........Water table depth..._.VL... �i SEPTIC TANK n Type/M1`4 Q.. Capacity _�''`U No. Compartments PKG. TREATMENT PLT.CJS Method of Disposal Distahce to nearest: Weil Foundations O _ Property Line _ LEACHING LINE No.&Length of lines --- � . ��'lm Total Iength/size FILI,,ER BED r 5�i Distance to clearest: Weil/0FoundationG.;�r�0 Property Line SEEPAGE PITS «i I Dooth• Site Number SUMPS L'I Distance to nearest- Well ...._. Foundation Property Line D1SOOSAL PONDS '7 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laves, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: *l 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."Contractors hiring or sub-contracung signature certilies the following:"licertify that in the perforinanca of th"e"vto`rk for which this permit is immed,t shalt emptor/persons subject to workman's wropernsa- tion:iaws of California. The`applicant must call forTlu!rpd inspecir ns. Complete drawing on reverse`side. Srg ___-_ nad X_ �+�'.. __ 'iitle:+�� i'� •' Date: R DEP ARTMENT9"dSE ONLY Appkcation Accepted by ��'� '� •L ___. _ -_--- Dafe.__ _. Area Pit or Grout Inspection by Data Final fns ction b 1>s y .. . Additional Comments: _ _ -- Li Stk 485•67SI 1D Lodi 359.3571 0 Manteca 523-7104 ?racy 835 •t. Applicant- Ra'rurn all copies to: Environmental Health Permit/Services 1501 E.�H,azelton Ave,; P.Q. Box 2t>119,•Sik., CA 95201=-»'-' 4.;•' y'" 3 _FEf .i.AMOUNT.DUE-- AMbUN-T-AEMiTTf0- 0K —..f4EuivED-BY =-- -�--OA"Tt __. _ PERMIT'N0-- -- �..•.• EN fs•Te