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APPLICATION FOR PERMIT AAA 0 SAN JOACLUIN LOCAL HEALTH DISTRICT 3 1601 E. HAZEL i ON AVE., STOCKTON, CA � Telephone (209) 466-6781 ��✓✓ PERMIT °� EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) V J Application is hP,,eby made to the San Josiquin Local Health District for a permit to construct andior install the �� ton is made in compliance with San Joaquin County Ordinance No,x549 for sewage or No. 1862 for well/pump and the Rule wquin Local Health District. Job Address t7 4 -p _ City✓ Lot Size PM Owner's Namef!..__.r r/�6 _ Arfriresst1j�!-� 4tr tL Phone Contsaciot �+�,•� 12, W02, ..License Nof! TYPE OF WELL/PUMP: NEW WELL Ci WELL REPLACEMENT i:: DESTRUCTION 0 PUMP INSTALLATION F'` SYSTEM REPAIR n OTHER O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLD. _ PROP, LINE FOUNDATION .__— AGRICULTURE WELL OTHER WELL. PITSISUMPS INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �. _.....____ Ol __.. _.__. ndustrial t'."1 Open bottom i_;3 Manteca a. of Weli Exeavatio;7 _. Dia. of Wei)Cerin v C1 Domestic!Private- .n-Gravel-Pack--,-- Cl Tracy— ----,..Type of,CasinrJ-� __ Specifications M Public 1.1 Other L-I Delta Depth of Grout&Pal Typo of Grout_...... _ l trrataiiUrr —A . De pprox. Delon •� ,i/,1.��Eastern Surface Soul installed by.--, Repair Work Done i:�- Type of Pt,niprf " "" +✓`.._ H,P. .__._. State Work Dome—. Well Destruction L3 Well Diameter Sealing Material atop 501 Depth r _._.._ Filler Material IBelow 501 _.... . __._ ... TYPE OF SEPTIC WORK: NEW INSTALLATION '.I REPAIRIADOITION i l DESTRUCTION I I (No set' ystem permitted if public sewer is r _ a e within 700 feet.I installation will serve: Residence Commercial..__ other Number Of living units: N bier of bedrooms Character of soil to a depth of' feet._ ...Water table depth SEPTIC TANK C1 Type/Mfg _Capacity.__ -- No. Compartments PKG. TREATMENT PLT. Ll A Method of Disposal ...�_ Distance to nearest, l__.... Foundation____._ Property Line II i LEACHING LINE 1.`1 NO &Ler of lines Total lengthisize.. FILTER HED n crista to.nearest: ' well_ Foundation _ ._�_. . Property Line I _. SEEPAGE PITS i i Depth _____.......— .__Size .-..— SUMPS L) Dis;tanoe to nearest: Well Fou tion Property Line DISPOSAL PONDS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws,and rules and reguiations of the San Joaquin Local Health District. Home owner or licensed agent's signature candies the following: "I csrtify that in the performance of the work for which this permit is issued, i shall not p employ any person in such manner as to become subject to workman's compensation Wws of California."Contracir s hiring or sut>contrauing signature certifiers the following, "i certify that in the terformanca of the work for which this permit is issued,I shall employ parsons ss,t,ject to workmans compensa- tion laws o, California.,, The applicant u call r sal r uir inspection . Complate drawing on r rse side. g _ S, nes X_ � �'C.�'��-�'" rr DEP A TMENT;USE ONLY Application Accepted bye- - t_5 _ .__. Pit or Grout Inspection by Date Final Inspection by Dar ",_ f Additir real Comments: r_ + L.1 Stk 466-"" C Lodi 365.3821 C Manteca 823 7104 0 Tracy 835-6385 i Applicant - Saturn all copies tn:Envirrrn`mernai Health ParmitiServicas 1601 E. Hazelton Ave., P.O. Box 2t>09, Stk., CA SVOI I _ 1 PEE AMOUNT DUE AMOUNT REMITTED _ INFO CASH RECEIVED BY DATEQ PERMIT NO. Em 13-24 n fH 11-216 TREY,i s n 5) '"'�'.�a,�C` '7-,)-)—6e) lee—top 7