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APPLICATION FOR PERMIT ..-* SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 .. PERMIT EXPIRES 'l YEAR FROM DATE ISSUED r., (Complete in Triplicate) .,, , 4-),,, - :I, •, ;: 1. 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 'Local Health District. 'made in compliance with San Joaquin County Ordinance No. 50 for sewage or No. 1862 for well/pump and the Roles and Regulations of the San Joaquin _ - ! Ili . /41,67., Ilt Job Address PM City4 Aot size Owner's Name _1e/Alii:ri" PIC-1._.geRN4Kidress Phone 11 • TYPE OF WELL/PUMP: Contractor -4/0er---_-•Address L License4lo,•442-47-*7 Phone zrze- 3 9 7/ NEW WELL D WELL REPLACEMENT El DESTRUCTION 0 OTHER IT! '• 0 Delta etp Depth of Grout Seal _ ID Eastern • kSurface Seal Installed by Li Manteca Dia. of Well Excavation PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ AGRICULTURE WELL. OTHER WELL_ • F'ITS/S_LIJVIPS _ Tracy, Type of Casing__ • * DISPOSAL FLD. PROP. LINE Type of Grout Specifications Dia of Well Casing • . State Work Done ilble • in 2 feet.) pakE s,4 7.S.1 @ Home owner or licensed agent's signature certifies the f011oWind:•"1 celtify 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•ccimpensation laws of California." Contractor's hiring or sub-contracting signature tion laws of California." certifies the following; "I certify that the peileoTirianCii5 tif tlie-7-vork-for Which dis permit is issued, I employ persons subject to workman's-compensa- te drawing on reverse side. Title: _Eitzez ."'" Date: < SUMPS 0 Distance to nearest: Well /SO Foundation OPP Property Line , DISPOSAL PONDS 't—C1 - - • •••-• - • - -- I hereby certify that I have prepared this applicatio-n'an'ci that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin LoCal Healthlpietrict. I/ Is D , D te,4raiiAJ, SEPTIC TANK Character of soil to a depth of 3 feet: ii-AR-D PAA/ a.- e.--i-Ay Water table depth a.....""Typ/Mfg .e. 0- '-- P d.-- L._ \ Capacity / (P 6 0 No. Compartments PKG. TREATMENT PLT. 1-3 ' ll t 1 ,',/ k ,7 f ;', , Method of Disposal. Distance to nearest: - . Well 1 0 1•2 t Foundation J. ' Property Line 7S"' .; 'til 0,, \ LEACHING LINE '',""No.S/ LengthlOf line; ' • ' 3 — Szo ' FILTER BED Total lerigth/size_i_ 0 Dist3nce to 6arest! Well / 0 0 ' Foundltioin, .:24:7 ' Property Line. .7•C' 4' I! 3 ( i SEEPAGE PITS a3"-:Dept'il`trr ".;,/-S.' ' - :Size 3 3 'r \ Number _ .3 PUMP INSTALLATION 0 SYSTEM REPAIR EST: SEPTIC-TANK „SEWER-LINES-- FOUNDATION _ TYPE OF WELL Li Open Bottom 0 Gravel Pack FD Other _Approx. Depth Type of Pump _ Well Diameter Depth IF TYPE OF SEPTIC WORK: NEWI1NSTALLATION REPAIR/ADDITION 0 DESTRUCTION El (No septic system permitted if public sewer is INTENDED USE E. Industrial LII Domestic/private D Public El Irrigation Repair Work Done Well Destruction 0 DISTANCE TO NEAR r 16-s-tallatierrwill-servef--ResIdencev-Wi,Commercial_ 'Other Number of living units: Number:of bedrooms,- 3 Sealing Material (top Filler Material (Below 501 • The applicant must calf for all required inspections. Co pie Signed X_ - • e Additional Comments:- - E Stk 466-6781 121•=tddi368-73621 Applicant - Return all copies ‘to: Environmental •• Applicatido Accepted1:::w. tA < t Grout Inspection by FOR DEPARTMENT USE ONLY p -0 te.-4-er/24 Date Area _ Lt7r-701:e?I'l, Date $-OZ Final Inspection by El Tracy .835-6385 Health Permit/Services 1601 E. Hazelton Box 2009, 'Stk., CA 95,201 Li Manteca 823-7104 tZA1 [ ILErEo AMOUNT DUE + Eli 13-24 (REV. 5.1 Eli 14-26 AMOUNT REMITTED CK * CASH RECEIVED BY DATE 9-84 PERAAI Af-sa Am,