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r i le3!F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1fi01 E. HAZELTON AVE., STOCKTON, CA i Telephone 12091 466-6781 U �� . . PERMIT EXPIRES 1 YEAR FROM DATE,ISSU IJ(Complete in Triplicate) `- F � k9� 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!`oaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and athgtR;VleS,ani pegulalibnsi,d {he San Joaquin Local Health District. Job Address ( 3 1 7 City Lot Size PM 3 Owner's Name Address *-r''� Phone 0. D Contractor '�+ I o ddress ��. moo' _ License No _Z-_ Phone � TYPE OF WELL/PUMP:.tiNEW WELL ❑ WELL REPLACEMENT ElDESTRUCTION ❑ vi, OTHER Vis- PUMP�lNSTAL-LA7``107V.❑R_ .._ =—, .S,YSTEM.REP.AIR-_❑ � _ - �. .. - DISTANCE TO NEAREST: �`EPTIC TANK �F SEWER LINES DISPOSAL FLD- PROP. LINE FOUNDATION t AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE hTYPEOF G17ELL,h PRO LEMAREA - ONSTRUCTlDIV SPECIFfC4TIONS�"'� �' ❑ Industrial '}' ❑(iOpen Bottom El Manteca Dia. of Well Excavation ' Dia. of Well Casing 0:: Open Domestic/Private 0 Gravel Pack 12 Tracy Type of Casing Specifications 1"1 Public f- Other I ❑ Delta -. Depth of Grout Seal ti Type of Grout I I Irrigation JF _Approxi D th I I Eastern Surface Seal Installed by t Repair Work Done C- Type of Pump H.P. 004 State Work Done t Well Destruction ❑ Well Diameter �M Sealing Material (top 501 Depth Filler Material (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION E I DESTRUCTION I 1 lNo septic system permitted if public sewer is ud i + available within 200 feet.) Installation.will serve: Rei�idence_ C I�mmercial— Other Number of living units: 4� Number of,�bedrooms ± �� ih � Character of soil to a depth of 3 feet: I'Water table depth t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 3 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑1. No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 1'11' Depth Size Number { L - F -.- -�_ .-. �^-+�s+�.�_-_ -•�� -_ SUMPS 77 Distance to nearest _ Well Foundation Property Line DISPOSAL PONDS ❑ I I hereby certify that I have piepared this application and that the work will be done in accordance with San Joaquin county ordinances, stale laws, and rules and regulations of the(San Joaquin Local Health Di3trict. Home owner or licensed agent's signature ceAifies 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 bec4ne subject to workman's compensation laws of California.",Contractors 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." The applicant st c for all re ed inspetti s. Complete drawing on reverse side. L ai ; �-- 3— Signed X di I� le: __-._-..�.)��, Date: FOR DE ARTMENT USE ONLY17 k Application Accepted by ____ Date ~6 Area 17 Pit or Grout Inspection by ' Date Final Inspection by�/�7� Date Additional Comments: II ❑ Stk 466-6781 ❑ Dodi 369-3621 II: ❑ Manteca 823-7104 ❑ Tracy 835-6385 ell, r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE jl' � 6 AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. Ilb I� +.EH13-21IREV.tin51 —1 EH 14-28 i 999 I