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,S APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (249) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED = (Complete in Triplicate ,. . rlication is permit to constru Application is hereby made to the San Joaquin Local Health District for a e#and/or install the work herein described.This app r _ ...: made in compliance with San Joaquin County Ordinance No. for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. ( �w 9g I 1 -J dot Size PM 4 Citys � 8 Jab Address �= Phone Address . Owner's Name CQ License NO hone RLI Z�Address 5b c Contractor DESTRUCTION �❑ "" -NEW WELL❑' p .-WELL REPLACEMENT ❑ �7 ---TYPE-OF WE 4 '" SYSTEM REPAIR D OTHER ❑ i PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE o - �"� SEWER LINES �1 DISTANCE TO NEAREST:; SEPTIC TANK OTHER WELL-- -- - PITS/SUMPS Y .FOUNDATION -- __AGRICULT.GRE-WEL-L— - -- CIFICATaOi INTENDED USEit TYPE OF WELL ' ..'PROBLEM EA CONSTRUCTION SPE ISIS Dia. of Well Casing <. Dia. of Well Excavation ❑ Industrial ❑ Open Bottom ❑ Manteca Specifications _ ElDomestic/Private L� ❑ Gravel Pack ` 1 Ll Tracy Te of Casing -Depth of Grout Seal Type of Grout P11 n .❑'Delta - ❑ Public ❑ Other h. El Irrigation �4pProx. Depth ❑ Eastern Surface Seal Installed by i j iH.P. State Work Done Repair Work Done ❑ Type of Pump H P i .) Well Destruction ❑ Well Diameter - Sealing Material-itop 509 .j J. `' Filler Material IBelow 501 `t Depth TYPE OF 5EPT1C WORK: iVEW INSTALLATION D REPAIR/ADDITION ❑ DESTRUCTION ❑ aNailabpelwit ine200 feet.) tted if public sewer is .�:. 3 °x'1 -_ Lfii rn Installation will serve: Residence commercial the- 1 5- 1^aur^� ate! l ! Number of living units: A- Number of bedro ms—. � -Y Water table dep�h. a ;.haracter of soil to a depth of 3 feet: _fib '^�a� Capacity �'�"�- No. Compartments m SEPTIC TANK i�rype/Mfg a f J n Method of-Diisposal , ! PKG. TREATMENT PLT. ❑ '� l Property Line / oundation F j Distance to nearest: Well W _ ! t Q + Total length/size- LEACHING LINE & Length of lines OQ Foundation 11L_— Property Line�.� 4-• o FILER BED Q Distance to nearest: Well�— r( SEEPAGE PITS 110�epth S rt Size SUMPS F ��Nu�mber 11 Distance to nearest Well r Foundation_ _D Property Line r �6 t DISPOSAL PONDS ❑ � ��-- 1-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 forwhich this'pe'rmit is issued, I shall employ persons subject to workman's compensa . do of California" The appiica t call for Ire fire�in ,�fC�plet, drawing on verse side. J. 5-`9?-< Signe Title: T Date: FOR DEPARTMENT USE ONLY4�'" -7 � r ' Date !fir �" Area F Application Accepted by w 1 Z Y Dat Final Inspection by Date Pit' r Grout Inspection by Additional Comments: EJStk 466-6781 ElLodi 36.9-3621 ❑ Manteca 823-7104 11Tracy 83`5-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E Hazelton Ave , P.O. Box:2�009, Stk., CA 95201 v FEE AMOUNT DUEJjAMOUNT REMITTED� C RECEIVED BY x1RATE PERMIT`NO. INFO + 1113-24(REV.1/951 - R O� Sib > ,. /.�� S c- y97Ile EH 14-26[