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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 tYEAR FROM DATE ISSUED T�; s (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 Sari Joaquin County Ordinance No.549 for sewage or No. 1862 for well/PUMP and the Rules and Regulations of the San Joaquin Local Health Y ' City w�-/�v r ' Lot Size PM ,lob Address / / f lJ 0nx-4e �� Phone Owner's Name �l S' Address !� C 5 ,1>0c/e r7 4 S a�i9 epil]4 IlS-8S3 /0a,11 Y ,4— �c�l�_ �Z �-0 AuJSD Address P��Roz s ense No./ `rry �Phone;7 j TYPESOF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER mon d k ; 86 DISTANCE TO NEAREST: SEPTIC TANK SEWER.LINES DISPOSAL-FLD. PROP. LINE � FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE.OF WELL. r�.PROBLEM AREA-- CONSTRUCTION SPECIFICATIONS �,[fj-/�,�_l �b[ C Ind tr ❑ Open B{ttom ❑ Manteca Dia. of W&ExcavDia. of Well Casing Type of Casing �f� P✓C� Specifications ❑ Domestic/Private C�G ave[ Pack ❑ Tracy g— / 1 Ll Public ❑ Other .1 ElDelta Depth of Grout Seal — O Type of Grout CCIr�� w ❑ Irrigation I Pprox. Depth ❑ Eastern Surface Seal Installed by e+' 1314' H.P. State Work_Done �!\ Repair Work Done El Type of Pump, Well Destruction ❑ Well Diardeter:. _W �-.' I Sealing Material (top . _ 9 ! Depth . Filler Material (Below 50'l TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ !DESTRUCTION El (No septic system permitted if public sewer is Il k �Jk vavailaI31S within 200 feet.) T Installation will serves: Residence' Commercial— Other it�►#'��Clot Number of living units: Number of bedrooms t4 Water table depth ! Character of soil to a depth of 3 feet: SEPTIC TANK Ll Type/Mfg { " ` `Capacity 11 Compartments ( 'L MI thod of Disposal PKG. TREATMENT PLT. ❑ 1 it efl W. *: Distance to nearest: Well . Foundation Property L.me LEACHING LINE ❑ No. &Length of linesTotal length/size t( FILTER BED ❑ Distance to nearest: Well.•- .FOuitd tion Property Line F f +. '" _Size � 6S Numbs SEEPAGE PITS C* sumps Depths SUMPS ❑ Distan etito nearest Well Foundation ,Property Line DISPOSAL PONDS ❑ 1k I hereby certify 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. 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 of California."Contractor's hiring or sub contracting signature employ any person in such manner as to become subject to workman's compensation laws 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 co hpensa- tion laws of California." "I The applicant mut all for all requir d i spections. Co to drawing o/n� reverse side. , Z" A Signed Title:eq�LG e�51 f Date: _- ' FOR DEPARTMENT USE ONLY MiC�� Application Accepts y ^ r. ..� -7 Date —(o— Area�. Pit or Grout Inspectio y �1° Date Final Inspection by Q Date I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369- 1 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: nvironmental Health Permit/Services 1 1 E. az®It�AP.O. Box 2009, �tk., CA 95201n 1— i R�5/ M i�i { s -'FEE INFO � lNOI�NT�DUE• AMOUNT RE ITTED CK RECEIVED BY DATE PERMIT"NO. + EH 1&24(REV.t/65) `1 EH 14-26 -