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✓"' .. APPLICATION FOR PERMIT SAN JOAQUIN.LOCAL HEALTH DISTRICT t 1601 E. HAZEL-Ri AV"E., STOCKTON, CA �. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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. ; ,,15 cif 6r��-G o 3 i Job Address City S7xt/ Lot Size PM Owner's Name W• TESEPl 7-4/77-LP—EP Address _—_40-0f 49f Phone 4 Contractor A1.0 A10612i Address' 7A AD Lt9��T E License No.404ySY7L Phone" 9k7 TYPE OF WELL/PUMP: 'NEW WELL ❑ WELL REPLACEMENT ❑I DESTRUCTION ❑ + ""PUMP'INSTALLATION-11— `�'SYSTEM-REPAIR❑' OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ; FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS—- x ❑-Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r ! ❑ Domestic/Private ❑ Grave! Pack ❑ Tracy Type of Casing Specifications n 4.'1 1 f'1 Public n Other 171 Delta Depth of Grout Seal - -.Type of Grout+tr I I Irrigation; Approx.,Depth LI Eastern_ �Surfacee Seal Installed by y _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ "`� 4 Well Destruction ❑ Weil Diameter Sealing Material Itop WJ ' T - Depth Filler Material (Below 50'1_ P TYPE OF SEPTIC WORK: NEW INSTALLATION I] -REPAIRIADDITION DESTRUCTION I I (No septic'system permitted if public sewer is Q 3 t / available within 200 feet.)..' rf` ' Installation will serve: Residence Z--commercial. "Other -•_ __ __ _ ___ Number of9living.units: _ Number of bedrooms Character'of soil to a depth-of 3 feet:_ CL ✓� T- Water.table-depth:- - SEPTIC-TANK y,X Type/Mfg �-�' - PSL Capacity 19&0 No.-Compartments PKG. TREATMENT PLT.;❑ .�--� � # ;y Method of Disposal i i ,/� Distance to nearest: Well — Foundation 4 Property.Line' .� LEACHING LINE VN, & Length of lines 4^ 9d Total length/size i FILTER BED ❑ Distance to nearest: Wel! AJIA Foundation .� ."^ Property Line..__Z0. "SEEPAGEiPITS I 1 Depth Size Number SUMPS " ❑ Distance to nearest: Well" Fo%indation Property Line DISPOSAL PONOS ❑ f. tx,.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 I rules and regulations of the San Joaquin Local Health Di1trict. Home owner or licensed agent's signature certifies the 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 to become subject to workman's 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." The applicant must call for all required inspections. Complete drawing on reverse side. . Signed XTitle: :rn 1at- Date: /47 ^RC DEPARTMENT USE ONLY Area Application Accepted by �v'^�� - •--."Date Pit or Grout Inspection by < Date Final Inspection by Date&p__ t. Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I 4 ' FEE 41 OUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO +.EH 1324!KIEV.s i x 51 �. EH 14-2e