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APPLICATION FOR-PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT P , 1601 E. HAZE T ON AVE., STOCKTON, CA , Telephone (209) 466-6781 t PERMIT EXPIRESEI YEAR FROM,DATE,ISSUED (Corilplete in Triplicate) .Application is heieby made to the San Joaquin Local`Health District for a permit to construct and/or installrthe work herein described. This application is made in compliance with Sari 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 ....J 1� '� City Lat Size PM . qc Owner's Na �+eQ 1 . fx► i P:�'fi�, dres's, _ 1t Phone s .� ContiacEor +� _ Address Fis :•i` L cense ho429 -I Phone TIP DF,INEL'LIPUhIlP , 7 WMEL! ''z-'DESTRUCTION ❑ -^-- - - ��. = ' �r PUMP INSTALLATION ^SYSTEM REPAIR'❑t ' -OTHER ❑ 4 DIST.ANCE.TO NEAREST: SEf?71CTANK: ` ' SEWER LENS. �J l _ aI DISPOSAL'FLD: t - PRO.P:•LINE . t FOUNDATION' '`:AGRICULTURE WELL -' + )OTHER;=WELL :pIT51S1JMPSl�0 r * INTENDED USE TYPE OF,-WELL. ., PROBLEM AREA CQNSTRUGTION_SPEOIFICATIONS z J r "r p Industrial >Apen Bottom-r-- 0 Manteca ` Dia. of WeIlfiExcavatiop Dia bf Well Casing. Domestic/Private =: �7.G.�avel'PacK. ;',' ❑ TracyF Y Type of Specifications I�lOther ['lbelta �De th of�Grbut Seale' _ a r�tV. r: _ i.: •:� ..ir t- ��._ x.r q.5-: •TypGrouY1?.�t1rQ y rl,islrriyatron { -Approxr�Deptti ' i I Eastern •'rfaci3`Seaf Installed' mit , r F - . Repar Work Do e Q Type of Pump ' �H P'»-� c .�_ State Work;ponePAI a{i�,tterr�-0A -3e Well'pestruction (] ;WeIIDiameter � : •Sealing Material-4top 50 lr-- -=- �:t_ - ,. yl ' { Depth 1 Filler:Material fBeiow.•; 0'L'`' i TYPE!OF SEPTIC WCIAK:.,.NEW INSTALLATION I 1 REPAIRIADOITION ! I f]ESTRUCTION I I 'i.No_sep'tic system+permitted if public sewor is r available,within 200 feet.) Installation will serve: ResidenceComrrlercial LL._ )Other 1 Number of living._units � �� Number of bedrooms Character of sod to a depth'of 3 feet: r '3 r' s r Water.table depth ' - :SEPTEC TANK 7' T' IC : 4 Ca acrt -� „� " r r p 4 Y No Compartments 1 ' PKG. TREATMENT PLT ❑ _ t + ` - \ Method of Disposal., Distance,to nearest: Well - 4 tiFbundahon _.Property Line• LEACHING LINE CI No: &'-.Leh96.df lines �'- s t Total length/size• I . c FILTER BED f ❑ .bIstant5e.tb nearest x ,Well ; =r .Foundation's z Property Line ` SEEPAGE PITS I 1 D'�pth Size 4 Number Sl1MPS , 'Distance'to nearest Well 1`' >Founaatidn Pro a Line -DISPOSAL' p rtY: L v.k. d hereby certity that I have prepared.this application and"that.ifie work will be.done {n.accoirdance with=San Joaquim bunty ordinances, statB Iaws, and rules end regulations of the Sari Joaquin`Local Health`'Di'strict: ---� * ' Homeiownai.o�licensed agent's�slgnatura certifies the folibwing': "I'certify that in the performance of the wdik for which this permit is issued,'I shall not employ any person in such mannar,as to be come-subject-to workman's compensation laws of California,': Contractor's hiring or sub-contracting.signatu re i r a certifies the following: "I certify,thai in the performance o-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 required,inspectio%.'Complete drawing ori Yrevarie side., Signe' ,d ;Tifle ' €€€ Date• x '.FOR DEPARTMENT•-USE bNLY. ;y 4 p6t tion Accepted by - -bate ` ` � Area s Pit or Grout.Inspection by•� Data f/` Final (6spec-`n.by Date' AddkiInal-Comments:. =. ►'� _ y_ _ _ r��_� _ ) U Stk{ 466 6781 ❑ Lodi 369-3621" _C Manteca`=823-7104 -❑;Trsc" ._835-6385 Applicant- Return all copiesto:`Environmental'.Healfh Permit/Services 1601 E. Hazelt n Ave.,'P.O. Box 2009, Stk., CA 95201 FEECK INFO MOUND DUE'S AMOUNT REMITTED, CASH RECEIVED 13Y. DATE PERMIT'NO. i r.-EH 13-I4 1 pE'V.r i H 51l