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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL I ON AVE., STOCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED sl (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 Job Address 2D 9s-o ly IiayI S Ado City � Lot Size 70 AC0446 PM �JAlO 9S'�22V� Owner's Name ,r Address/�©• L7 �/ Q !'1• Phone Contractor T A AddressLs� 7� T icense No. g�� Phone23-646,1 TYPE OF WELL/PUMP: NEW WELL/ WELL REPLACEMENT ❑ DESTRUCTION 4 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK IM'*--. SEWER LINES �d a z �' DISPOSAL FLD./M'* ; PROP. LINE/9_,f FOUNDATION /r/lL4- AGRICULTURE WELL/6&� OTHER WELL�D PITS/SUMPSCiN - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ? !! E] Industrial 1-1OpenBottom El Manteca Dia. of Well Excavation Dia--of Well Casin NoDomestic/Private Gravel Pack LJ Tracy Type of Casings C Specifications C � S�6a ,.... ❑ Public O�er = El Delta Depth of Grout Seal .fiA Typedf Grou ❑ Irrigation , ' 0 Eastern Surface Seal Installed by � I Repair Work Done ❑ TypeE of Pump _ H.P. State Work Done F Well Destruction ❑ Well Diameter Y Sealin *Material 9 (top 501 f Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑o'REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system,permitted if public sewer,is " + available within 200 feet.) xl i Installation will serve: Residence_ Commercial Other . Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK �.❑ „Type/Mfg, Capacity No._Compartments PKG. TREATMENT PLT. ❑ .' R' ` Method of Disposal " iyDistance to nearest: Well Foundation _ Property"Line. �+ ? R LEACHING LINE ❑ No. & Length of lines f Total length/size FILTER BED ❑ ~'Distance to nearest: 'Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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. 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all requi ins ctions. Complete drawing on reverse ide. _ }} Q Signed X__&eJ- Z _ Title: 5 Date: /0 F DEPARTMENT USE ONLY Application Accepted by Area I Pit or Grout Inspectio Date P 1?1 inel Inspection by `�` Date ---------- Additional Comment .W":��,-1,. -1.1 Aug 5='� - ❑ Stk 466-6781 ❑ Lodi 389-3621 ❑ Manteca 823-7104 racy 835- ' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE �` ' AMOUNT REMITTED ^CK# " RECEIVED BY DATE f PERMIT''N0. INFO) `CA/SH _ T'tj + EH1}2g1flfV.t/957 EH 1428 r lll//fsso 4 Q1(✓�'