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APPLICATION.FOR FOR, SAN JOAQUIN LOCAL HEALTH DISTRICT �6 1601 E. HAZELTON AVE., STOCKTON, CAy ' Telephone (209) 466-6781 ry ' 5-r P, i. 5Z :'i>k f�i •-i. ..i ,. �, .� .. PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED .., • �; E. ' s r 1W :� : lg nv�., � 1�°��. ;�=r %):,l Complete in Triplicate);,c� l 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 made in compliance with Son Joaquin_County Ordinance.No.549 for sewage or No. 1862 for well/pump and the Rules:ar d Regulations of the San Joaquin Local Health District. :1 5-E ii 1-l � � E Cr': ✓._ # .f* t iiT_:. " r; .. �.�. Job Address City 2 C A Lot Size!' PM Owner's Name l C:1s a' M Address / _ Phone Contractor's Nam License No. Phone TYPE OF WELL/PUMP:. I t' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTICTANK SEWER LINES DISPOSAL FLD._ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION'S �❑ industrial ❑ Open.Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing © Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public . ❑ Other ❑ Delta Depth of Grout Seal i Type of Grout i ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump, H.P. b State Work Done i a Well Destruction ❑ Well Diametei W _ :Sealing Material (top 50') Depth 5-f" i Filler Material (Below 501 vQ TYPE OF SEPTIC WORK: NEW INSTAL161%, I.fV ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No se tics stem Q. p y permitted if public sewer is r, -available within 200 feet.) f Installation will serve: Residence Cammetcial_ Other Number of living units: Number f bedroom's •� c Character of soil to a depth of 3 feet" Water table depth " SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ' Distance to nearest: wall Foundation Property Line f� yA LEACHING LINE No. & Le]4[ th d1lines Total length/size_;>,�' ti FILTER BED ❑ Distance to nearest: Well Foundation /A Property Line - FSEEPAGE PITS ❑ DepthSize' Number SUMPS .:❑ Distance to nearest: Well, , 4 t.. Foundation Property 0641' DISPOSAL PON DS ❑ i 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 regulations of the/San Joaquin Local Heplth District. _. - -t, - - Home owner or licensed agents signature certifiesVhe following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as'tobecome subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the fdllowing:"I certify that in the performance of the work for which this permit is issued,I shell eri ploy persons subject to workman's compensa- tion laws of California." J� _ _ -1 ":r v w-j. The applicant:must call for all required inspectlons.YCornplete drawing on reverse side. ' ' �� T �� Signed i ' Title: �' " Date: _lam !. �r ' FOR DEPARTMENT ONLY Application Accepted by Date r '- reaAb- ? f, Pit or Grout Inspection by �r Date loo Final Inspection,by�"' Date�r �. - Additional Comments: ..°" ❑ Stk 466-6761 ' —0 Lodi ?M-36211-1- brManteca" 823-7104--, ❑ Tracy /835-6385 i Applicant- Return all copies to: Environ±,6l_f1eaith..Petmk/services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,;CA 95201 �llFVF� rAMOUNT DU AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO.' +EHx1324{REV.101$31 ; 4 EH 14-28 li S• t] I Z�O —t r-{ 9