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t APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in.Triplicate) _ Application is hereby made to the San Joor No. 1662 for we aquiri Local Health�pisirict for a permit to corist�uci anii7o�install-the'work heFein`descr'iEsed"�Tfiis applica"tion is made a compliance with San Joaquin County Ordinance No.549 for sewage Blpump and the Rules and Regulations of the San Joaquin Local Health District. !G �A� C' Lot Size -0.r`X /Y z PM Job Address 3 yy /SAG% •--- - City��• �-�~ ' Phone -"N 7-- S!l.H7'e�.f Address �/gCIFiG Owner's Name a t C .,m c7e,, Y j�,0- %1 So'"�O Address �� BLls� License Na. Phone Contractor - DES TYPE OF WELLIPUMP ❑ TRUGTION El: NEW WELL ❑ WELL REPLACEMENT �'` SYSTEM REPAIR ❑ OTHER ❑ PUMP INSTALLATION ❑J - SEWER L r. DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK LINES ��— PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE.OF.WELL' PROBLEM AREA-.--CONSTRUCTION SPECIFICATIONS Dia- of Wel! Casing ❑ Industrial ❑ Open Bottom•-`^T D Manteca Dia. of Wel! Excavation Type of Casing Specifications ❑ Domestic/PTivate ❑ Gravel Pack L ❑ Tracy Depth of Grout Seal Type of Grout [7 Public ❑ Other ❑ Delta _Approx. Depth I 1 Eastern Surface Seal Installed by ! I Irrigation — State Work Done — Repair Work Done ❑ Type of Pump H-P.' `., if Sealing Material Stop 501 + Well Destruction ❑ Well Diameter Depth I Fillet..Material IBelow 50'1 n TYPE OF SEPTIC WORK: NEW INSi ALLATION REPAIRI,ADDITION 1.1 DESTRUCTION'l i aNailabpelwslhinc sys e200 feetitMi d ii public sewer is f Cot Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms i SAA/d Water table depth Character of soil to a depth of 3 feet:g / .'t o d No. Compartments ❑ Type/ Pie CHsT CaR/Gr, Capacity SEPTIC TANK s Method of Disposal I PKG. TREATMENT PLT. ❑ 1 /,+j- •f` Distance to nearest: Well 90 ` Foundation Property Line Total length/size LEACHING LINE ❑ No. & Length of lines , /ff" property Line i FILTER BED Distance to nearest: Well Foundation � .-_-.--•-•-..--.,,...--_ Size Number SEEPAGE PITS [ I Depth Property Line SUMPS ❑ Distance to nearest: Well Foundation DISPOSAL PONDS ❑ will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared rules and regulations of the San Joaquin ths application and that the work Local Health District. 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 signature shall not employ any person in such manner as to become subiect to workman's compensation taws of California-" ploy Contractor's lect to workmanor ' s compensa- certifies the following: "I certify that-in the performance of the work for which this permit is issued, I shall employ persons I tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Title: Date: Signed X FOR PARTMENT USE ONLY `Area v Date - Application Accepted by Pit or Grout Inspection by Data Final Inspection t Date l Add onal�Comments: l ❑ Stk 466-6781- ❑ Lodi 369 3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Retu n-all copies to: Environmental Health.Permit/Services 1601 E. Hazelton Ave.,_P.O.NBox 2009, Stk., CA 95201 } i � s CASH RECEIVED 6Y DATE PERMIT NO. r IFEE NFO AMOUNT;DUE AMOUNT REMITTED + EH 13-24 1pEV.t/n 51 D u Byre R EH 14-2e