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q I APPLICATION FOR PERMIT SAN.JOAaUiN LOCAL HEALTH DISTRICT fi 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (.209) 46&67$1 PERMIT EXPIRES VYEAR FROM DATE ISSUED' ,, (CompleteFin Triplicate) = c Application is hereby made to the San Joaquin Local Health District fora ;A ac �� rt made in compliance with San Joaquin County Ordinance No.549 for sewage No. 1 construct all,plump andl the Ryles and Regulations of the Santhe work he in described. Thi liJ Joaquin re Local Health District. r Job Add �. -J I bn r«tr#to- . f� city of Size ' PM' Owner's Name Address l iC 7i.: C� rc � Phone l . Contractor Address License No. Phone " TYPE OF WELL/PUMP:p WELL ❑. WELL REPLACEMENT ❑ FDESTRUCTION Qr1 .^ PUMP INSTAL-L-ATION-❑ -.-.,-.,...�'gYSTEM.,REPAiR�❑- .- F' 3 DISTANCE TO NEAREST; SEPTIC TANK SEWEth LINES "" "- '"`OTHER ❑- -- - W-- »�. , �� DISPOSAL FLD. PROP. LINE FOUNDATION AGMCULTURE�WL-L--�t. OTHER WELL INTENDED USE PITS'/SUMPS "TYPE OF...WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS `'V ❑ industrial ❑ Open,Bottom ❑ Manteca Dia of Well Excavation ` ❑ Domestic/Private ❑ Gravel Pack ❑ TracI. Dia. of Well Casing AlY E1 iType of Gasing f ❑ Public + Specifications QOther # ❑ Delta Depth of Grout Seal Type of Grout El Irrigation 11y, yF. T Approxi epth ❑ Eastern Surface Seal Installed by I Repair Work DoneyiO Type of Pump H p State Work Done Wall�l7estruction C Well-Diameter- � . , �: Sealing Material (top 50'1 . 1 Depth h:.s, I- Filler Materia! (Below 501 4 ti TYPE OF SEPTIC WORK; NEW INSTALLATION 010 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted ff public sewer is ��' <, •� �� available within 200 feet.) � Installation will serve, Resi once Commercial ther Number of living units: Number bf bedrooms y ! Characteu,of soil to a depth of 3 feet: ' SEPTIC TANK;b:,> hype/Nffg 4 W�alter table depth +� 3 •"� PKG. TREATMENT PLT. ❑, " f t F. { Capacity a- 4 . Compartments ° ~fir / Method o Disposal Distance to nearest: Weli Foundation�� I Property Line LEACHING LINE 48"'�lo, & Length of�Iines '�'"`, d iFILTER BED Total length/sizeI+� Distance to neares Foundation lir Property Line ft a 0=7k, / SEEPAGE PITS ❑ Depth "f-a I Size .W, I SUMPS Nymber �'~'bistance to nearest: Well Q Foundation ! Property Line t DISPOSAL PONDS ❑ _ M Pro I ;: --4 y certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and l rules and regulations of the San Joaquin Local Heafth District. i Home owner or licensed agent's signature certifies the following: "I certify that in the 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."Contractors hiring or sub-contracting signature certifies the following:"'I certify that in the performa ce of th work for which this permit is issued,I shall employ tion laws of C rnia." p p y persons subject to workman's compensa- tion applican ?-"Tr st cal!for If required ins ctio Co ete drawing a erre side. ' Signed Title bate: } FOR DEPART ENT USE ONLY - y A130ation Accepted by (� Date Area rout IrFV n by Dater Final Inspection by Date t. Additional Comments: / r �� ❑ Stk 466-6781 ❑ Lodi 369-3621 EJ Manteca 823-7104 ❑ Tracy 835-6385 Applicant Retum all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO - -CASH RECEIVED 8Y DATE PERMIT"NO. +EH 13.24(REV.1/85) r EH 14.28 ©: * tot 4 A r aro-;� _ t ... ,-, i. .,. -.... ...r_ •. �..�..V. ,.-.w.. _._.\. � _'-�'