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i 1i APPLICATION FOR PERMIT I� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA"-' Telephone A "- Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 made in compliance with Sanhe . This application is Joaquin County Ordinance�No.549 for sewage or No. 1862 for well/pump and tRules and Regulations of the San Joaquin Local Health District. Job Address f City Lot Size �-;kr PM Owner's Name it1 Address - 7 758 '--"`�� Phone I Contractor's Name �.. Z -�, r�l License Na :2- >,TPhone --JJ> TYPE OF WELT/PUMP: NEW WELL ❑• WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL _ PROBLEM AREA CONSTRUCTION SPECIFICATIONS a•-. T � .. ❑ Industrial i El Open Bottom �❑ Manteca Dia. of Well Excavation Dia. of Well Casing � I ❑ Domestic/Private ' ❑ Gravel Pack Cl Tracy Type of Casing X Cl Public - Specifications i ❑ Other 0-Delta- .t �; _.Depth'of Grout Seal Type of Grout 6 ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal.lnstalledkby Repair Work Done ❑ ' Type of Pump H.P. State Work Done s Well Destruction ❑ f Well Diameter Sealing Material (top SO') i Depth Filler Material (Below 50') # TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR_/ADDLTlDN,❑ DESTRUCTION ❑ (No septic system permitted if public sewer is _ �•. _IR Installation will serve: ' � ., - — —�—ova ilable=within-200=feet-) 'Residence - Commercial 0 er - Number of living units)-/ Number of bedrooms, Character of soil to a depth of 3 feet: a .r SEPTIC TANK 'TNo. Compartments Water table depth s Type/Mfg Capacity (! PKG. TREATMENT P-L7;❑ Methd` :of,Disposal 3 Distance to nearest: llflell� 4 FoundationProperty Line d LEACHING LINE ;. No. & Length of lines -^ Ya'S 7- j-•-- Notal length/size i FILTER BED ❑ Distance to nearest:. Well - 'S Foundation1 ' Property Line SEEPAGE PITS ❑ Depth NumberSUMPS Distance —r A - t Foundation Property Line DISPOSAL PONDS ❑ t. �. I hereby certify that I have prepared this application and that the work will be done in accordance with San`Jo4quin county prdinances, 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 thee,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 tki permit is issued,I shall employ-persons,subject to workman's compensa- tion laws of California." The applicant must call fo all required inspections. Complete drawing on reverse side. ', <• 'I j'. } Signed Title: Date: r s FOR DEPARTMENT;USE ONLY Application Accepted by ° # Date - Area Pit or Grout Inspection by Date ir # Final Inspection by Date 6 -/�4; I Additional Comments; ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 023-7104 D'Tracy"835-6385 Applicant- Return all copies to: Environmental Health permit%Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I " FEE - AMOUNT DUE AMOUNT REMITTED .^C k:' s•. INFO - =CASH,.1� -RECEIVED,BY - ..�a .DATE.__ .. _ PERMIT-NO.� +EH 13-24(REV.10/63f y� �� O �pu �.---L EH 1426 / `—+4� .. 1 Y-7/ 6 `S ��•1_I