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n � APPLICATION FOR.PERMIT SAN JOAQLit� LOCAL HEALTH Di51RICl 15CI E. HA.ZELTON AVE., STOCKTON, CA PERMIT NO. # Telephone (209) 466-6781 DATE ISSUED �� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED- t } (Complete in Triplicate) 9. Application is hereby made to the San Joaquin Local Health District for a permit t6 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 Address A-9 4 I�U�'��✓ Subdivision Name 1 Owner's Name Address �� 3 L•Sfle-ZIL �sob Phone ; Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION i .. �=. PUMP,1NSTALLRTION ,..SYSTEM .REPAIR. , �. .��:..a _.OTHER._U., �,"� �... „ .-T� -•G.-.. " � � i 61 STANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL, _ PITS(SLIMPS } INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIF�CATIDNS �i Industrial :� f 'I—� Open Bottom Manteca Dia. of Well Excavation_ i U Domestic/Private Gravel Pack U Tracy Dia. of Well Casing< h PubliGii � Oher Delta Type of Casing E V Irrig3Cln Approx. ❑ Eastern Specifications , Cathodic Protection Depth Depth of Grout Sea I + M Geophysical Type of Grout U Other Surface Seal Installed [by e of Pum State Work Done Repair Work Done �`J TYP - p H.P, Well Destructio+� ;Well Diameter•-_.__ Sealing Material (tip 50') �-- - ,._ Depth „ Filler.Material (Below 50'} � s• � I TYPE OF SEPTIC WORK: NEW INSTALLATION' ) REPAIR/ADDITION "`('No septic tank or seepage p,itfpermitted' if public sewer is :available within 200 feet.} Installation will serve: Residence Commercial Other nits: Num of bedrooms,,,,,,(((((( of (Number of living u r 'Character of soil to•a depth of 3 feet: 4laterfitfable dep �=, '{ �� Capacity a�-No. Compar nts �... SEPTIC TANK Type/Mfg1. PKG. TREATMENT PLT: Type/Mfg i i Capacity > Method�of Disposal 4 1Foundation - Property L� nez} SEWAGE SYSTEM Distance to nearest: �We11 " i DESTRUCTION , . ' No. & Len Length of lines a ;Total, I. n th%size e ..� LEACHING LINE jJ g e (- FILTER BED ] Distance to nearest: Wel'1 Fouidation 2 I Property ane? rj SEEPAGE PITS Depth Size i ' `IVumb2r ?•!fti, tt _�- - ,. Property Line f SUMPS �� Distance to nearest: WellFouhdation ,, P DISPOSAL PONDS r,�^- I hereby certify that I have prepared this applicationiand that the work will bene in accordance with San Joaquin county ordinances, state laws, and rules and regulations 6f�the-San 'Joaquin Local Health District. +` a Home owner or licensed agent's signature certifies the following: "I'..certify that in the performance ofithe work for which this permit, is issued, I shall not employ any person in such manner as to become subject to workmank compensation lawsjof California." Gontract3r's hiring or sub-contracting signature certifies the following:, "i certify that,t;i.n the performance of,the work for which this permit is issued, I shall employ persons subject to,'workman's compensation laws'Of California"' : a The ap"licant"must call for quir inspections. C6mplete drawing on revers J * o bate: s �� S'igned x F RTMENT 115E D ONLY i Area 'Application Accepted by ? _ k y Lodi 369-3621 $ $Additional Cammeri£s': f Manfe " Date ` 1 c-V823-104 y JPit or Grout Inspection by ' � L--, 835-6385 i tom, a add cam- jai Date -� -* . 0 Tracy i Final Inspection by - - -—^ A i Applicant - Return all copies to: Environment 1 Health °ermat/Services 1601 E. Hazelton'Ave., P.O. Box 20D9, Stk., CA 45201 i FEE a BASE AMOUNT DUE AMOUNT'REMITTED \RECEIVED BY DATE PERMIT N0, ik INFO 1 ,' t � 4 . ,..�.. -10/az 500_.. A EH 13-24 REV. 10/82 t 14-26 .