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f 4 r'r �,�;�{"f'�`i}��,�-�,�r,�r��{t,irfy�°� E ,p�rt �>°+:r.s� r,'. i •y. T 1- �.�T�n t��i�� V. �I� n tn; -:3�� u. ''�•'.,.:r 1 ,y, ,' t! r^9�.k,11 - t�/ j ' Y' .. . i r APPLICATION FOR i'ERMIT - -• - - ' ' SAN JOAQUIN LOCAL HEALTH DISTRI;ET • `' 1' 1601 E. HAZELTON AVE., STOCKTON, ',A Telephone 1209) 4&;-6781 rr 4 : .. _ PERMIT EXPIRES 1 YEAR FRC`M DATE ISSUI_D �• (Complete in Triplicate) Application is hereby made to the San Joagv:n Local Health District for a permit to construct and/or install the work herein described.This apNlcaifon is merle In compliance with San Joaquin County Ordinance No.tr49 for sewage or No.1862 for wel!/pump and the'Rules and Regulations C11 1141 San Joaquin r • Local Health Distric.. x �,�Ll �__ 11Y_1--/(/(7•� �(� Lot Size i-��1.�1LS.al.l PM Job Address t.. 4t �.. 9 11sI1 f9 asap �u Owner's Name lZ91 h�A —L —zS Phone �Cll ddress pe I�� pci mp5S onti'actor, StAddress s- ge-f'� R)dr _License No.�/ /Phone " _ TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ r SYSTEM REPAIR ❑ OTHER 0 y DISTANCE TO NEAREST: SEPTIC TANK Rn r SEWER LINES r z DISPOSAL FLD.- r PROP. LINE 52.iZJ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS._ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Inl trial ❑Open Bottom ❑Manteca Dia.of Well Excavation _ Dia,of Well Casing .L� (FYDomeslic/Private vel Pack ❑Tracy Type of Casing___I (Tee� Sprcifi,ationT Gr ('I Public ❑ Other f"1 D61ta Depth of Grout Seal ,—� __ Type of Grouts Y t I Irrigation __Approx. Depth I I E3slAmi Sutfaco Seal Installed by RepAir Work Done ❑ Type of Pump H.P. _ State Work Done_ Well Destruction Cl Well Diameter Staling Material(top 50.1 t Depth Filler Material(Below 50.1 b TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDI7IQ N I I DESTRUCTION I I (No septic system permitted if public sewer is i V available within 200 feet.) ( Instt':ation will serve: Residence_ Commercial_ Other Number of 4v;ng units: Number of bedrooms r Character of soil to a depth of 3 feet:_ _, — Water table depth_ ?' SEPTIC TANK 0 Type/Mfg ___ Capacity_ _ No.Compartments S .. PKG.TREATMENT PLT.0 Method of Disposal ` Distance to nearest: Well Foundation _ Property Line LEACHING LINE 0 No. 8 Lenpth of lines Total length/size— f FILTER BED ❑ Distance to nearest: Well _ Foundation' Property Line _ SEEPAGE PITS I I Depth Size Number i„ SUMPS Li Distance to nearest: Well Fc•Indation_� Prooerty Lisa - 1 DISPOSAL PONDS ❑ r { r I hereby certify that I have prepared this application and that the work will be done ir,accordance with San Joaquin county ordinances,-state(arks,aro► rules and regulations of the San Joaquin Local Health D13trict. Home Twner or licensed apent's signature certifies the following: "I certify that in tho performanca of the work for which this permit is issued,I"trot employ any parson in such manner as to t>a oma subject t0 workman's compensatio i laws of California."Contractor's hiring or sub-contracting signatum certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's cor pensa- •'k tion laws of California." The applicant ca far all raquired ins cttions. Coomplote rawing on rreeveerso!ide. Signed X� . Yom+--�'/ _ _ Title:�Ls_� '1 Date: FOR DEPARTMENT(ISE ONLY }1� ApplicaAccepted by / Date 'Q-_ Area_JT Pit Cdt �J inspection by n, Final Inspection by _ Date I • Additional Comrrientr: 107y _— D Stilt 466-6781 ❑L i 369-3621 12Manteca 823-7104 0 (racy 835 6385 Applicant-Return till rApies to=Environmental Health Permit/Services 1601 E. �azelton Ave., P.O. Box 2009, Stk., CA 95201 j FEE } INFO AMOUN7 DUE AMCSUNT REMITTED RECEIVED BY DATE PERMIT'N0. EN 1124 fPEV.trn�1 , "lT 4�C t •y S/ � 5, EN l4le V O \�I O 1 �— Ili