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' APPLICATION FOR PERMIT SAN JOAQUIN-.'pLOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES III YEAR FROM DATE ISSUED '4 (Complete in Triplicate) ,h. Application is hereby made to the San Joaquin Local Health District 4for 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 we I/ and the Rules and Regulations of the San Joaquin Local Health District. e/, / /� �C3f 8� City Lot Size . �/}t/G� PM Job Address Address ✓ Phone ' Owner's Name,` /�: �'`�� Adds sad 3a� Phone Contractor _�02 License No. fTYPE OF WELL/PUMP: �I NEW WELL!❑ �" WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION`❑ 1� SYSTEM REPAIR Cl OTHER E3 DISTANCE TO NEAREST: SEPTIC'TIANK '' SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E] Industrial ❑.Open Bottom 0 Manteca i Dia. of Well Excavation Dia. of Well Casing Specifications El Domestic I Private ❑EGravel-Pack - ©Tracy-- j� Type of Casing e, Type of Grout El Public ❑.Other E ❑ Delta j JJ Depth of Grout Sea-(l EJ Irrigation _Appr x. Dept .:,[D-Eastern 1 i1: Surface Seal Installed by Repair Work Done ❑ Type of Pump i H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material /top 501 r` O Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) l ! 7k nce Co Commercial_ Other Installation.will serve: Reside � , Number of living units: Number of be oo is Character of soil to a depth of 3 feet: aWater table depth SEPTIC TANK i Type/Mfg �� opacity dZ9 No. Compartments C G I� f Method of Disposal PKG. TREATMENT PLT. ❑ x' Line `f Foundation d Property ne Distanceto n :!5-. S f . earest: Well —�— _ i �- LEACHING LINE No. & Length'of lines �IV Total length/size f� d 7Property '~ FILTER BED � ❑I Distance o nearest: Well Foundation�— Line rr Number SEEPAGE PITS L'�DepI_ 1172 th � Size /6, f4- Pro a Line SUMPS D. Distance to nearest: Well_LS2 — Foundation P rtY DISPOSAL PONDS Ell I hereby certify that I have prepared this application and that the cork will be done in accordance with San Joaquin county ordinances, state laws, and wo rules and regulations of_the,�San-Joaquin_Local Health--District.- I� Home owner or licensed agent's signature certifies the following:y'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."Contractor's hiring or sub-contracting signature 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- tion laws of Calif ia." The applican u all fo II required inspections. Complete drawing on reverse side. 11 T Signed Title: — Date: 11 FdR DEPARTMENT USE ONLY ' Application Accepted by I i Date Area !M ^ e s dr Pit r Grout Inspection by Date / �i Final Inspection by ,.# Additional Comments: ❑ Stk 466-6781 ❑;Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i th Permit/Se09 rvices 1601 E. Hazelton Ave., P.O. Box 20 , Stk., CA 95201 Applicant- Return all copies to: Environments! Heal FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. /NPO + EH 13.24IREV.1/85) EH 14-28 I t,