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Co APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZ_TON AVk., STOCKTON, CA Telephoner(209) 466-6781 AR FROM DATE ISSUED D RERMIT EXPIRES 1 YE , (Complete in Triplicat l) t I l� , Application is hereby made to the San Joaquin Local Health District for a'permit To'consttuct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump an�the-Rules and Regulations of the San Joaquin Local Health District. City C ;Lot Size PM Job Address t Phone�r Owner's Name + � Address Contractor s-- Address ;7� Cg,,17 License No.14111f Phone 5 � TYPE OF WELL/PUMP: I� NEW WELL WELL REPLAGEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM'REPAIR 71❑ ; OTHER ❑ I a it j „� DISPOSAL FLD. �PROP. LINE JAV [ DISTANCE TO NEAREST: SEPTIC TAMC- SEWER LINES �� FQUNDATION f ? AGRICULTURE WELL OTHER WELL_ PITS/SUMPS qIF i # INTENDED USE TYPE OF WEL 1 PROBLEM AREA CONSTRUCTION SPECIFICATIONS a ❑ Industrial�\ C� ❑ Open Bottom ❑ Manteca Dia. of Well Excavat16n Dia. of Well Casing DomesticVPrivaate �)Gravel Pack ❑ Tracy Type of Casin Specific V t Type of Grout I'1 Public ' N� Vin' ther ❑ Delta Depth of Grout Seal yP t �C a �r� - I I Irtigation� ^ 4 ' pptox. Depth J I Eastern S� Seal Installed by i -l r�I '1' P. State Worst Done Repair Work Done 40th INM of Pump J, H.P. �� J. Well Destruction ❑ Weil Diameter --'' S�'riing,Ma�terial (top 5A - Depth Firldr Materia! fBelo50y TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDIT�gN 1 F-4RE S7 UCTION I1f lVo septic system permitted if public sewer is Q )avail'ble within 200 feet.) (\v Installation will serve: Resifndence_ iommercial — Other dcv Number of living units: t�! Number if bedrooms r t` Character of soil to a dept Fiof 3 feet: ` - Water table depth I SEPTIC TANK Q I Type/Mf gapadityi ! No. Compartments PKG. TREATMENT PLT. ❑ i !� Method of Disposal Distance to narest: Well Foundation Prop;rty Line I F t 1 LEACHING LINE ❑ No, & Length of lines TotAl i ngth/size FILTER BED © I Distance to nearest: Well �• Foundation Property Line SEEPAGE PIT ( I Depth Size r Numbr f SUMPS t^Jlls- Distance to nearest: Well Foundation Proprty Line DISPOSAL PO ❑ t I hereby certify tha[ I ave prepared this application and that the work will be done i -eccordance,+�+rith S�n Joaquin county ordinances; state laws, and rules and regulations of the San Joaquin Local Heal District. y- »r11 . ; Home owner-or-licensed.agents signature certifies th 1�Dllotetittg _cectify�*wt in the fberformanc the work fbr which this"permft is issued, I shall not employ any person in such manner as to become sub$ct to workman's compensation IAws of Ca5fbrihi C' ontractor's hiring or sub-contracting signature t '1 certifies the following: "I certify that in the performance ort a work for which thisperrrnt is issued,l shall el€tiploy persons subject to workman's compensa tion laws of California.'�A �� I {��x The applican r requir S. Complete drawing on rave a side. f Signed X A Title- , .. i p FOR DEPART V4SE-ONLY,l N Ll Application Accepted by 11 f.Da i _ Area to{ Pit or Grout Inspection by �� Date° — Final Inspectlo by 3 Date ` f , Additionar C.mments: ❑ Stk 466781 Q Lodi 369-3621---� .Q-Mantece-823 7184 ❑ TrcY' a -835- 385 y" A plicant -- Refiifrn all copies to: Environmerital Health Permit/Services 1601 E. Hazelton Ave., P:O.. Bo 2009, Stk., CA 95201 FEE ~ AMBUNT DUEL 'AMDIJNT REM1TfED `CASHRECEIVED'BN' PATE PERMI7'N0. INFO i r-EH 13-24 tHEV,I i n 51 �lJ r" EH 14.29 It � ' w" x I t