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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE,, STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Appli'cation's hereby mads to the San Joaquin tonal Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San JoaQuin County Ordinance No, 545 for sewage or Net. 18U for wail/pump and the Rsiiss and Regulations of the San Joaquin Local Health District. Job Address P! 0 111 ." .4 G,�'7! iI%.E b.- ativ ir..lf b 1.... - - Lot Size A,&- Pi lf.01 Owner's Name */ 0, Address _.� C' Phone Cnntta;,;cr _.Qli,? Wed l%.,_... _ Ad dress J t Li/l.V 15t�1_icense No. i'_... Phone TYPE OF WELL, PUMP: NEW WELL LW WELL REPLACEMENT (- DESTRUCTION --- ._..P_UMP_INSTALLAIION-.i_ SYST.I:hr J;EP.AIR_j;J_..._._._w____ - _-OTHER�:i��.._ _ DISTANCE TO NET: SEPTIC TANK _ SEWER I_INE5 . DISPOSAL FLD.-�,.,_.,, PROP. LINE _.._ _.... _.._ ARES_.._ .._ FOUNDATION AGRICULTURE WELL _ _ . _ _ OTHER WELL P1TSiSUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS sl C Industrial U Open; Bottom 0 Manteca Dia. of Well Excavation �_ _ _ Dia. of Well Casing _. I_I Dornasticiprivate :._. Gravel Pack O -racy Type of Casing._—.__.. Specifications y . LI Public ": Other ❑ Delta Depth of Grout Seal _ _ Type of Grout-. 0 Irrigation-----....,..,,..---.__Approx, Depth i -..Eastern _ Surface Seal Installed by Repair Worts Doyle 0 Tye of Pump H.P� State Work Done Well Destruction M. Well Diameter Sealing Material (top 501 w r �.... Depth .. ._ .. _ _ —F4IJr Material (Below 6i7'} l' TYPE OF SEPTIC WORK: NEW INSTALLATION i_ REPAIR/ADDITION LP DESTRUCTION 3 (No'septic system permitted it publi6,iewer is available within 200 feet_.) r linstallation will serve:Residence — Commercial O er Number of living units: __.._.I Number of bedrooms r Charecxer of 5tii to a deptof B feet —<- . LA #/ Water table depth��_ l SEPTIC TANK 1Capacity No, Compartments w _ PKG. TREATMENT PLT. W ±J , -' _ M6thod of Disposal'r,...,.ww .° Distance to nearest: Wit ! Foundation Property Line � I �: TEACHING LINE Length of lir;,4-jj�� y Total length/sizeX7 `r FILTER BED �.. Disirrnare to nearest: Well _ Foundation _.J ' � Property Line SEEPAGE PITS',--•- x r�� r ' D]' r .. Size Number SUMPS r, _ ' Distance to r,sarest Well -10 4.. t Foundation _ - � Property Line ,� � ._ .__ ✓ DISPOSAL•PONDS " t%. { I herby Certify that I hsve'prepsred this application and that the work will he done in accordance with San Joaquin county ordinances,'state laws, and rulss4nd-regulationsarf-the San Jriaquin`L-ocal H,eatth Di3tr"rd I Horne owner or licensed agent's signature certifies the folknnrng l4er fj4 hgt in the"pi r46riii iii the woWfot which this permit Is 'issued, i shall not employ any person in such manner as to 8acome subject to workman's compensation laws of California." Contractor's hiring or sub -contracting signature F1 certifies the following: "I certify that in of the work for which this permit is lowed, I stall employ persons subject to workman's compensa- r. tion laws of daiif6miaw- s The applicetrt;must call for all (squired Ins p i . Compute drawing: on reveres side. IL ,a x Signed 3C'e,__r�.�Et��r I fl;'� t Date: ! '..#.._. d FOR DEPARTMENT USE OAli:Y Application Accepted by _ Dazs �d'tArea ' t r Grout Inspection by � -�^✓ ___.._ Dats � ts�" Final I � � i nepection by :..-- ~ { Date .� i ✓ /1 � y�C✓ ^ L 4, Additional Comments: Zila�-_ Z.4) eell,CrL dw.�. -�l s' i 'd✓ Lam!% - ._ s Sik 466-147$1 0 Lodi 3W-3621 Ci Manteca 823-7104_ C Tr�>yrs ilppT'car { Karam all tipies to ErnnronnwMal Hsaith Pe;;; tOrvlces Y Ss$b'I E. Hazolton� Ava., 'P -O Bort X3_08, St b1W µ� s EN'a 24 MEV,'9 S;si Em 14.29 FEE t O AMOUNT DUE AMOUNT REMITTED CAK RECEIVEO IVY DATE I EAMIIT NO. r -y