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APPLICATION FOR PERMIT SAN JOAO.UIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466`6781 i + PERMIT EXPIRES 1 YEAR-FROM DATE 'ISSUED' 1 (Complete in Triplicate) IE Application is herebl.y 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 Ryles and Regulations of the San Joaquin Local Health"District. Job Address t?y+ City /1Al .r F Lot $lie 'r PM Owner's Name,, �`� �� ll.L dares ' :S "� ZD "� �� Phone Contractor/.Q�r,��_S/�f �OItJ�S' _Address - . /•I,L� �i7�1Licens7 o Phone Com' T €' TYPE OF WELL/PUMP: _, NEW WELL LJT❑ ElWELL REPLACEMENT DESTRUCTION INr r7 PUMP STALLATION ❑ - SYSTEM-REPAIR`❑ OTHER ❑ 'DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,ter ❑ Industrial ❑ Open Bottom -❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casiha, Specifications I ❑ Public 1 ❑ Other "-^'" ^"' ❑`"Delta""" Depth of Grout Sea] Type of Grout ❑ Irrigation t Approx. Depth j❑ Eastern Surface Seal Installed by -- - -' { Repair Work Dane 171Type of Pump i H.P. Z' '7; 1 State Worko Done _ ;Well Destruction ❑ Well,Diameter Sealing Material Stop 50`1 ' } k Depth j Filler Material (Below 50'1 ` TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ RiPAIR/ADDITION ❑" DESTRUCTION.❑ (No septic system permitted if public sewer is "�lavail able within 200 feet.) Installation will serve: Residence_ +Commercial Other Number of living units: Jk tNumber of bedrooms " Q!J. '" #4 Character of soil to a depth sof 3 feet: � ' '� Water tablefde th P ..3 SEPTIC TANK 11 Type/Mfg Capacity NoCompartments (7 PKG.wTREATMENT PLT.'1-1 Method of Disposal ? i !F / ,,4 Distance.to nearest:. Well (�� Foundation � r f�P'eoperty Line -A. I. v LEACHING LINE (�NO. &`Length of lines ''3 4�� - fToial lengtlilsize 06 ` FILTER BED_ �,,„ DaDistance to nearest: Well �" Foundation ` •Property Line I 33 3 SEEPAGE PITS i'Ir'7Depth 1 z Size E Number SUMPS r 3 ❑ :Distance to nearest:, Well ' -k �- Property Line } DISPOSAL PONDS t . ❑ �- 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. , R ` 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 for which this per is issued,I shall-employ persons subject to workman's compensa- tion laws of California." ( The applicant all f all req ' d inspections: Complete drawing on rever"side: i �,.x r7 Signed 4 Title: Date: U `i - Y FORDEPARTMENTUSE ONLY �. Application Accepted'byn Date � Area 6 t96 Pit or Grout Inspection by Date ` inal Inspection by Date UVJ dditional Com ants: — +� t4W -Ml 4 -67$1 ❑ Lodi 369-3621 w. C1 Manteca-. 823-7104 Tracy,.835-6385 "`�"`Ap ficant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 r "^^°""".'.-„`.FEEINFO*.' •"AMO,, CUNT DUE AMOUNT REMITTED 'CASHK RECEIVED%6Y f DATE. PERMIT"NO. •.r''.,��-y ' 40 + EH 13-24(REV.t/6 51 _T "ter '" ` EH 14-26 l t4VV//•••• J"+s