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4 Ji R APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT %01 E. HAZE-Li-ON AVE., STOCKTON, CA AV � Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED j (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. This application is 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. f Job Address ©[fi7 ' I City=-`��, Lot Size PM Owner's Name I60401s Address / 7�.{� Ct -r� Phone ' a d ;t Q Contractor Address -�S 0/0/ License WELL-REP- Phone TYPE OF WELL-/-PUMP: .---�-..,�.—.,^,E.W W6L�0L-AGE�VIE.NT d---=—�--^ESTRWCTION,-O t I it PUMP INSTALLATION ❑ SYSTEM REPAIR LJ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LIfE " L FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS - I i INTENDED.USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS \f ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public Ll Other n Delta Depth of Grout Seal Type of Grourt I I Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by f Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material (top 50') C> Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION IW REPAIR/ADDITION I 1 DESTRUCTION l I INo septic system permitted if public sewer is C- i. - available within 200,feet.) Installation w ill serve: Residence e/' Commercial Other Number of living unify ,� Numbero drooms. , Character of soil to a depth of 3 feet: -' _ Water table depth t SEPTIC TANK p'fypeLMfg Capacity I&rU0 No. Compartments PKG. TREATMENT PLT. ❑ 1`''� Method of Disposal t Distance to nearest: Well r Foundation a{ Property Lined T LEACHING LINE (IYNo. & Length of lines Vol Total length/size O FILTER BED ❑ Distance to nearest: Well f Foundation+ f Rr S I Property Line SEEPAGE PITS 14---Depth w�5 I Size v � �` �' Number SUMPS Ll Distance to nearest: Well `�S0 � �. Property Line --L� Foundation © � �f J DISPOSAL PONDS ❑ ' 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 HealtK'District. ` Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this per is issued, I shall not employ any person in such manner as to bei ome subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fdllowing: "I certify that in the performance.of_the-workJor which this permit is issued, I shall employ tion laws of California." + P Y persons subject to workman's compensa- tion } The applicant must call for all r uired inspections..Complete drawing on reverse side. 060,V-1 Signed X � Title: Date: 3t �AW, DEPAR MENT USE ONLY �i Application Accepted by DateA !J f re/a� Pilor Grout lhspection by c°'r ate `l"'� Final Inspection by Date`s''// (� Additional Comments: ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104 Cl Tracy 835-6395 Applicant - Return.all-copies.to:_Environrnental..H.ealth_Permit/.Services 1601_E._Hazelton_Ave„_P_,O-_gox.2009;.Stk.,_CA..9520i� FEE UE AMOUNT REMITTEDCK 41 INFO AMOUNT DCASH L/�.//f RECEIVED 6Y DATE PERMIT'NO. +.EH 13-24 1REV,t i K5) EH 14-28 dro �tJ. TO // (� L/ C1 i