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F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . (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.-649 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 4; jli60 '' I yh r-�e -tf: �.tlfS •.7 i<.�'f -,�f. F..F .. . .. c .�1 r A,. ,,, 1 r . r Job Address �y.�} QG' Tfl iQl1 City 7Y C, — Lot Size PM ` -i, - —; I Owner's Name ��YY r� 5�i`.� 4�i/An�* Address Sh��t� � _ Phone ry Contractor's Nam, 19 .St'A�ri License'No-t yyy Ail Phone ,TYPE OF WELL/PUMP: _ NEW WELL ❑:v i WELL REPLACEMENT ❑ DESTRUCTION 171 f} r PUMP INSTALLATION El . SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES i DISPOSAL FLD.__ PROP. LINE — 1 FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Weil Casing s❑ Domestic/Private ❑ Gravel Pack ,❑ Tracy Type of Casing, t - Specifications ;❑ Public ! ❑ Other ❑ Delta Depth of Grout Seal Type of Grout -❑ Irrigation i ---Approx. Depth ❑ Eastern Surface Seal`Instailed by I Repair Work Done ❑ € Type of Pumper -„w H:P.., ti I State Work Done �- Well Destruction ❑ Well Diameter Sealing Material (top 501 j Depth Filler Material (below 501 F TYPE OF SEPTIC WORK: NEW INSTALLATION,X REPAIR/ADDITION ❑—DESTRUCTIOM,0 (No septic system permitted if public sewer is ^ s =- ^—available within 200 feet.) Installation will serve: Residence_� Commercial Other Number of living units: Number of bedrooms --gr Character of soil to a depth of 3 feet: .vd .� Water table depth /m ' SEPTIC TANK '� m—T /Mfg ' - �tsT"�Ga vc. Capacitig— I Z4.00 No. Compartments PKG. TREATMENT PLT. F-1 of Disposal YW Distance to nearest: Well /GO Foundation fs' Property Line n I ( LEACHING LINE R No. & Length of lines 9A ` Total 9 1 � Total length/size FILTER BED "' ❑ Distance'to nearest: Well Foundations Property Line �! SEEPAGE PITS ❑ Depth Size Number �,SUMPS ❑ Distance to nearest: Weil ��D � Foundation �� Property� t y ��.f } 1 Line i DISPOSAL PONDS ❑ I "s 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 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, 1 shall not employ any person in such manner as to become subject tolworkman'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." t The applicant must all for all required inspections. Complete drawing on reverse side. /N ' Signed Title: f Date: 1 Y ~ FOR DEPARTMEI16 USE ONLY Application Accepted by Date �' Area r Pit or Grout Inspection by Qate Final Inspection by Date Additional Comments: 4 c,-.. LI Stk 46( MI ❑ Lodi 36.9-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009; Stk., CA 95201 k AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"N0. ,... .+.EH 13=24`IREV.101831— — �-�5� �• .. - ... �- e•-�' - - EH 1428