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I APPLICATION.F811.PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON.AVE., STOCKTON, CA Telephone (209) 466-6781 w PERMIT EXPIRES 1 YEAR FROM TE ISSUED s (Complete in Triplicate) 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 San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 'I�I Job Address � City r h Lot Size PM Owner's Name �.L_r v-� ^ C11), - Address Sa An Phone Contractor's Name Z) License No. Phone r TYPE OF WELL/PUMP: NEW WELL , WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION SYSTEM REPAIR ElOTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK D - SEWER LINESate'.-- DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF11VELL PROBLEM,ARFA -CON STRUCTIOWSPECIFICATIONS r� ❑ Industrial i '11 Open Bottom ❑ Manteca - Dia. of Well Excavation r pia. of Well Casing i Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications Ll Public ❑ Other ❑ Delta Depth of Grout Seal O 'd tf Type of Grout dtim Lo C7 Irrigation J0.pprox! Depth ❑ Eastern Surface Peal Inst led by . c ! Repair Work Dione ❑ Type of Pump` H.P. r State Work Done Well Destructidn ❑ Well Diameter Sealing Material.{top 50'} Depth. Filler Material {Below 50'1 `x"' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is s available within 200 feet.! Installation will serve: Residence_� Commercial_ Other �t Number of living units: Number of bedrooms 4,,-Character of soil to a depth of 3 feet Water table depth r SEPTIC TANKf :r---- ❑• Type/Mfg-• "' J. Capacity No. Compartments 3 PKG. TREATMENT-PLT. LJI _Method of Disposal e Distance to nearest: Well Foundation _IlProperfy Line a e +•, . i ' LEACHfNG LINE # F-1 No. & Leingth'of lines Total len gth/size FILTER BED ❑ Distance.i`to nearest: Well `y Foundation Property Line 0 r ' SEEPAGE PITS ❑ Depth �" Size Number + // SUMPS 4 `❑ Distancehto nearest: Well Foundation Property Line t DISPOSAL PONDS "❑ 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-Health District. '/1 ' v Home owner or liodhsed agent's signature certifies the following:-"1 certify 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 workmans compensation laws of California."Contractor's hiring or sub-contracting signature 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 compensa- tion laws of California." I The applic ust c for all require pectin Comp a rawing on reverse side. © k Signed i Title: a`r" Date: r FOR DEPA ENT USE ONLY i Appli ation Accepted by Date Zia 4 Area Pit or Grout Inspection by + Date `y Final Inspection byJBWfate 30 Additional Comments: ❑ Stk 4664Ml ❑ Lodi 369-3621 ❑ Manteca 82;5f7la `I] Tracy 835-6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 35201 Ip FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH a EH 13-24(REV.10/83) IIS loya7 1or-1 Elf 14-26 '" —13