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L APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT '; f 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (CCrrfMe*&4A-Tdp1icate) r 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 i t made in compliance with San 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. -w",— 1 Pw Job Address 131City 77T Lot Size / �G PM. Owner's Name .7,Pi ,i1� Dl ^Address Phone ' Contractor_ �� `(1 �� Address P. O License No.4;:�26aw Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ " DISTAN CE.TO.,NEA,,R T:,SEPTIC TANK', SEWER LINES DISPOSAL FLD. PROP. LINE.- FOUNDATION INE.FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SLUMPS _ j INTENDED USE TYPE OF WELL PROBLEM AREA' CONSTRUCTION-SPECIFICRTINS e ` ❑ Industrial 0-,Open Bottom , ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑'Gravel-Rack ❑ TracyType of Casing Specifications } M Public 1=1 Other,- t f Ci,Delta y ; Depth of Grout Seal Type of Grout I I Irrigation Approx. bepth_. I I Eastern-- , • Surface-Seal Installed by ti'. Repair Work Done ❑ Type of Pump H.P,, L`95tate�Work Well Destruction ❑ Well Diameter ' r$ealing Material Ifop 50'a'�` ' : Depth � t —l;ilfera Material-(Below'50'I` t TYPE OF SEPTIC WORK: NEW-INSTALLATION REPAIR/ADDITION l I DEST`RUCTION'l 1 (No septic system permitted if public sewer is available within 200 feet.l' Q ` Installation wilt serve: Residence -Comrierciafi�C_ lOtFier' �_�- E i Number of living units: _� Number of bedrooms Character of soil to a depth of 3 feet: l,ti D g� Water table depth I r SEPTIC TANK C] Type/Mfg Capacity s4Z2!02-_ No. Compartments I i PKG. TREATMENT PCT. 0."`% k•,� � 4.."� `� Method of Disposal I Distance to nearest: Well —._._7Foundation�i� Property Line LEACHING LINE l No. & Len th of firies'" off. T , E i g Total length/size r f FILTER BED �D �,Distande to nearest: W'I Foundation Property Line SEEPAGE PITS L-l—,D6pth _ `fv Size Number I SUMPS Distance to nearest: Well �� F�-- t�`!L Foundation F� Property Line f DISPOSAL PONDS ❑1 � I I.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 Di?;trict. j Home owner or licensed agent's signature certifies the followingr '.I certify,that in the performance of the work for which this permit is issued, I shall not s employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature I 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." r # The applicant must call for fl required inspections. Complete drawing on reverse side. I I 4 Signed X a"Ayp Title: • Date: # FOR DEPA MENT USE ONLY ' j - 7 v ✓ G Application Accepted by # Data Aea . , Pit or Grout Inspection by Date Final Inspection b f' i Date Additional Comments: i Cl Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 L7 Tracy 635-6385 Y Applicant - Return all copies to: Environmenial Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 FEI 'FEE v *AMOUNT-DUE -�AMOUNT-REMIYI•EDh ---CK'CASH FiECEIVER BY DATt FPERMiT'ND. '# ,," h-s wr..,EH 13-24 IREV�r i n 5) -�-..- -. ,.....<.--.-+%-T..-,,.-�--. .�.._. _I.-`�„-.W. EH 14-2a - C)