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fi f APPLICATION,F PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED - r {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 Ruies and Regulations of the San Joaquin Local Health District. ' ` - /: t T j�-��^- `y� �"J O{�.G�6>T J0 CLAM� #2' �J�'P7R / 1QAC� Ci pC/<TON Lot Size PM Job Address �. __ Owner's Name" A Ag I WC6A Address 12 6 a F AW'� A y Phone Y77- 4 063 d6 , , /�� V1 ATS� wT& `License No. �. a / Phone Co tractor s ame TYPE OF WELL/PUMP: NEW WEL'M WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION'S SYSTEM REPAIR ❑ OTHER El DISTANCE TO NEAREST: SEPTIC TANK-1SL, SEWER LINES o DISPOSAL FLD. _ PROP. LINE_ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATION far � r S ❑ Industrial- -M, ❑ Open Bottom-0-Manteca—Dia.-of:Wetl.Excavation��J --.-IDia:..of.well-.Casing—� Domestic/Private Gravel Pack El Tracy Type of Casing 7F' C Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal (Type of Grout To ❑ Irrigation ---Approx. Depth ❑,Eastern Surface Seal Installed by �_�/ G Repair Work DoneCf -Type of Pump c` State Work MOy�� X1�T�IfG �/ t Well Destruction—C7"_INell Diameter; =7 Sealing Material jtop 50'1?' _..._.___ TO ly�� _ i I � Depth l f Filld Material IBelow 501 1 r' i TYPE OF SEPTIC WORK: 'NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted1f public sewer is: k I c available-with3n-200-feet- Installation will s.4e: Residence_ Commercial Other # r Number of living units: I Number of bedrooms ?r -tet `( Cha racter•ofsoil-to-a-depth of 3 feet: =Water tabfe-depth SEPTIC TANK LlType/Mfg Capacity ' No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal ! 4 Distance to.nearest: Well ( ' Foundation Property Line LEACHING LINE ❑ No. & Length of lines j - Total length/size FILTER BED ❑ Distance tolnearest:"` -Well 1 F`o`undation t Property Line j� �, t'"'"p"`' SEEPAGE PITS ❑ Depth }w F Size ? - ' Number~�-- - SUMPS SUMPS ❑ Distance toirearest:—.Well- - Foundation r— P�aperty Line I i DISPOSAL PONDS ❑ 1; *_o-1 , I It-' I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,'stdte 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-kir4ng-0r-sub-contracting signature certifies the following:"I certify that in the performance of the-wo'r ffor which this permit is issued, I shall--employ persons subject to workman's compensa- tion laws of California." ('tS The applican st:—ll f 1 r uired inspections. Complete drawing on re arse side. � W/ � �/ �1 ✓ Signed r ,- Title: t/Y �1 TR/�C Td Date:a - # - _- `A FOR DEPAR NT USE ONLY i Application Accepteilby4 L� Dat Area f Pit or Grout Inspection bye 0�1 " Date A al Inspection by Data Additional Comments: tr — Stk 4664781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 OrTracy 835-5385 y Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.'Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"Nd INFO CASH EH 14-26 + EH 13-241REv.10/83)1