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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT *� 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 Address City_ /� Lot Size 'T PM Owneris Name b � ;\- 1 Addre s, t i<4 he,-* � 1� Phone 'r Contractor fl f?1 __ Address Cense No. f,?,??/ Rhone TYIPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl PUMP INSTALLATION ❑ f SYSTEM REPAIR ❑ OTHER ❑ ,r t,r• DISTANCE TO NEAFIEST: SEPTIC TANK SEWER LINESw\S DISPOSAL FLD. PROP. LINE1t , �- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ ��iPyTENDED US — • ZIYFE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial j -�-Opbn Bottom ❑ Manteca , .._._.Dia._oi WekExcavation s _- :� _ pia. ,of_ t-ell Casing ❑ Dc 113, LI�Grael Pack ❑ Tracy Type of Ca,si✓n�i!' �r^ Specific;tions 9 f i Public Cl Othe Cl Delta Depthf1Grout Seal Type of rout _ I 1 Irri aiion .�^. I g � ��App�x. Depth i I Eastern �Surface Seal installed by Repair W k' ones"0 )T1 of,Ptt" p � H,P.�� State Work Done i_ � I e...r , , �Y� Wel! Destru Don �❑ Well amdter '?p dealing Material (top 50'I 1 ` epth1�,filler Material 18elow 50'1 TYPE OF SEPTIC WORK: NE NSTAL TION I I REPAIR/ADDITION DESTRUCTION I INo septic system permitted if phblic sewer is e. f t_'" ----- - — available within 200 feet') f ` 3^S Installation will serve: Residence_ Commercial Other { T f Number of`livinb units: Number of bedrooms Character of soil to a depth of 3 feel. Water table depth SEPTIC TANK Type"iRfgl F Capacity i9 No. Compartments i PKG. TREATMEl PLT. ❑ ) Method of Disposal # DistaWWi' ;nearest: Wel{-- -- Foundation I I � i Property Line I * ` LE CHING LINE ❑ o. & Length of lines F Total leng /size FILTER BED 1 L1 tante to nea�es : Well Found a't n 3 Pro rty Line ' ' i � • SEEPAGE PITS I I,' Deptl � ) Size i Number S SUMPS. i LI� Distance` o nearest: Well oundation Property Lin 1 DISPOSAL PONDS ❑. I ! t I herebylcanify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and t rules and regulations of the San Joaquin Local Health District. '. -3 Home owner Or licensed agents signature certifies the following: "I certify that in the performance of the work for which,this permit is issued, I shall not employ any parson in such manner as to-become-subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:-'"k'ceatify tha['irl tfi'e performance of the work for which this permit is isaued, !shall employ persons subject to workman's compensa- tion laws of Califomi '- �,A _ ` I I I The applicant mu call for all required ' trio s•complete drawing on reverse side. GCom"' r Signed Y( � Title: Date: tr FqfIjWPARTKAENT USE ONL Application Accepted by 4 Date i Area Pit or Grout?Inspection by r�ti Date Final I specti by Date - {{�� . Additional Comm Pts: 41 +' AA � l •' <� �''�� '2= �- ❑'Stk 466-6781 ' Lodi 369-3621' ul'Manteca 8� -7104 ❑ Tracy e635-6385 •--•--Applicar4 -Return`an-baples to- F,-ron'mentai-Hi-.Itfi-Permlt ervl ec s 1601E/Haze'ton Ave., P.O. Box 2009, Stk., CA 95201 s FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 4 RECEIVED BY DATE PERMIT'No. A i 4-.�ur" �/� : ' � EH tt- 9 ».•rr