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i. APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA a !� 466-6781 I } PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � � f: (Complete in Triplicate) j 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. Job AddressQ�. � ) Y 9 1(�i.C° QCX3 rY :�]OY1 C City ✓'""' i s Lot Size !' f - PM Owner's Name y f �� 1 C°Address 'fit-C' C� 1 4 � '� Phone ti.Contractor (Address License No. Phone TYPE OF WELL/PUMP: NEW WELL © - i WELL REPLACEMENT 0 DESTRUCTION LI N, - RUMP-INSTALLATION ' --- - b S`STEM•REPAIR i]— �--� OTHER-171 i _DISTANCE TO NEAREST: SEPTIC TANK �"SEWER LINES I DISPOSAL FILO. :� PROP LINE k 'i FOUNDATION I� _ A�;RIC,ULTURE'WELL OTHER WELL PITS/SUMPS t ,INTENDED USE TYPE OF WELL; PROBLEM AREA CONSTRUCTION SPECIFECATIONSj 1 k ' 0 Industrial 0 Open Bottom 0 Manteca Dia. of-Well Excavation - t - a Dias of Well Casin �0 Domestic/Private 0 Gravel Pack 0 Tracy Type.of Casing Specifications —0-Public Ll Other 17 Delta Depth of Grout Seal Type of Grout I I Irrigation -- f —Approx. Depth I I Eastern Surface Seal Installed by I _ Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction 0 Well Diameter ti � Sealing Material (top 501 Depth Filler Material (Below 501 ' TYPE OF SEPTIC WORK: NEW INSTALLATION M' REPAIR/ADDITION l 1 DESTRUCTION I I INo septic system permitted if public sewer';i!s v' available within 200 feed) e Installation will serve: ResidenceL� Commercial Other Number of living units: .4 Number of bedrooms Character of soil to a depth of 3 feet: ; f i 4 9 fh/aterr�taGile deptt h s SEPTIC TANK f Type/Mfg :w r et-, _ Capacity f"d �3 f No. Compartments a (fes PKG. TREATMENT PLT. 0f �7 ; Method of Disposal �` !'��"' Distance to nearest: Well w " . � ' 1 "a Foundation Property Line +z__ LEACHING LINE I�No. & Length of lines" —,,A c Total,length/size'+ s ""�'�;e , ` / FILTER BED ❑ Distance to nearest: . Well Foundation r LA "Property Line i,f,__r i SEEPAGE PITS I 1 Depth a Size '-�f�Vumb_er li SUMPS Li Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ � 1 I hereby certifyahat I have}prepared this application-and that the work will be done in accordance with San Joaquin county ordinances, state laws, and { rulessiand regulations of.the-San Joaquin Local Health Diatrict. ► e Home owner or licensed agent's signature certifies the following: "I certify that in the performance,of the work for which this permit islissued, 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 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= j tion laws of, a ifornia." 1 I The applicant ust call f fall required inspections. Complete drawing on reverse side. Signed ! r orf ,� r Title: .,.'r r "�.. I Date: f i { R PAMENT USE ONLY - Application Accepted by Date J Area d Pit or Grout Inspection by Date Final Inspection by rDate ,I& ! I Additional Comments: .0 Stk-466-6781._--, 0 Lodi:-369-3621- 0.Manteca-.,.823-7104,.- -O. Tracy. -1135-085--- Applicant 135-6385,.,_Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box_ 2009, Stk., CA 95201 t q. v '1k 1NF0 : AMOUNT DUE »� '"AMpUNT-f)EmiTTEO CK S` RECEIVED<BY DATE o `'PERMI.7 N0. �- ..EH 13-24 1 REV.1 i A h 1 .. �s•t� /� t\—•�' C) EH 14-26 "1 V l`—... (7'�q� 1� �447 f