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.�L APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZELTON�AVE., STOCKTON, CA i Telephone (209) 466-6781 ` ! PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED (Complete in Triplicate) '.t- .. Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described:Tis 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. ` - I Jab Address,r f / �i � CL �' L�OSize t +..— �,,:._ ..,,. .._,, .- .,.. :l. ..ac+ ,.,�.._' `; �1i'�;.:a• .;t....,:. IsrWE.-wr�..-.:.'.:4 4.: PM 4:` ,..+ ...a-- .... Lot Owner's Name''-- 'Address L"Y � 2-��I�N�r.� Gi�(�� Phone A ",Z l Cbntractor-"•'.-•°` Address License No. Phone i TYPE OF WELL/PUMP: f NEW WELL ❑ WELL REPLACEMENT ❑ "DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ \ ' "t.OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO' , PROP. LINE i FOUNDATION ,z !AGRICULTURE WELL OTHER WELL + 'PITS/SUMPS e INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industria! " D Open Bottom -Manteca Dia. of Well Excavation Dia ofe`fI Casing ❑ Domestic/Private ❑Gravel Pack L1 Tracy Type of Casing Specifications ❑ Public c a D rOther ❑ Delta Depth of Grout Seal Type of Grout El Irrigation.V pprox. Depth ElEastern Surface Seal Installed by �w Repair Work Done ❑ Type of Pump j. _. H.P. State Work pone Well Destruction ElWellsDiameter: Sealing Material (tap 50') 'Depth 1V> Filler Material (Below-50') TYPE OF SEPTIC WORK: INEW INSTALLATION' REPAIR/ADDITION ❑ DESTRUCTION ❑'(No septic system permitted if public sewer is available within 200 feet.)- Installation will serve: ResidenceCommercials Oth'r 1 s Number of living units: Number of bedrooms 3 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg '' ' a<.- Capacity !��G G No. Compartments 'y',1 r Method of Disposal PKG. TREATMENT PLT. ❑ �t:✓r Distance to nearest: Well ��a' Foundation �� Property Line— LEACHING(LINE No. & Length of lines`1� we)011 To�al length/size �2 FILTER BED ❑ -Distance to nearest: ,Well Oo„. '"ro Vion 0 Property Line_ f SEEPAGE PITS �epth _ �� Size t f�umber SUMP �. °'3 ❑ Distance to nearest: Welly Foundations-la / Property Line S DISPOSALPONDS ❑ f 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-District. Home owner or licensed agent's signature certifies the following: "I certify that in the pertormance'of the work for which this permit is issued, I shall not employ any person in such manner as to become aubiect'to workman's`compensation laws of California.,"Contractors hiring or sub-contracting signature. certifies the following: 'I certify that in the performance of.the work for which this permit is issued,"1 shal!'employ persons subject to workman's compensa- tion laws of California." ` - I ". _�' !; The applicant must call for all-required inspections. pleteid�awing.on reverse side. � r �Q Signed - - - c e-= Title:- # Date:Z, �+V k FOR DEPART ENT.USE ONLY t Application Accepted by -� D'7---30 Area A- Pit or GroutDateFinal Inspection by Date es I.3 _ A ditional Comments: I St466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 LJTracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,iStk., CA 95201 +� a FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO 5—O QC,ASH +EH 1324{REV. /s 51 —30 -757 EH 14-28 + 1 /"p _ l o A.7