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n I I� APPLICATION FOR PERMIT A' SAN JOAQUIN LOCAL HEALTH DISTRICT z �! 1601 E. HAZELTON ON AVE., STOCKTON, CA q Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 1 l made to the'San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is Application is he+eby made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin { Local Health District. u li 3�� piAf�.S•.Gf1 ,p� City .57;rC-1J Lot Size d X' pa PM 6 Address + F/ nre /�I ."AAS' Address �� _ Phone TYP€ OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENI 'U utbIKM,I I, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ _ t �" I rr 4 Tnnw F_C. p1SPOSAL FLO._ PROP. LINE NEW WELL ❑ WELL REPLACEMENT LJ Ut:b I ttut,1 lu+'4 � TYPE OF WELL/PUMP: � PUMP INSTALLATION El ; SYSTEM REPAIR ❑ OTHER 1-1 1' LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER FOUNDATION � rAGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL{ PROBLEM AREA CONSTRUCTION SPECIFICATIONS(_,,,, _�.___�,_,. T�--.Q- Dia. of Vtifell Casing p ❑ Indu trial C) Open Bottom Ll Manteca Dia. of Well Excavation Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Cl Other ❑ Delta Depth of Grout Seal Type of Grout-- — f'1 Public - I I 1 Irrigation�. �.PApprox. Depth- l I Eastern`, Surface Seal Installed by Repair Work Done ❑ Type`of Pump �v H.P. State Work Done_ } k Well Destruction ❑ Well',Diametef ,,Sealing Material Stop 50'1 — Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I l alvailable+w thin 20system 0 feet+t�ed if public sewer is � a Installation will serJe ,„Residence k' Commercial-'' Other f jNumber of living units: Number of bedrooms iWater table depth r) Character of soil to a depth h of 3 feet: ' SEPTIC TAN ;.,;,., ' ._.Capacity 1 ZOO No. Compartments (� PKG. TREATMENT PLT. ❑ Method of Disposal � I Distance to nearest: Well 7 / Foundation © ' Property Line LEACHING LINE No. & Length of lines - g Total length/size 7e ir —4:c— FILTER :FILTER BED ❑ Distance to nearest: Well Foundation 40 Property Line a N ' L SEEPAGE PITS I Depth o2 s —Size �' 3 t Number r, k SUMPS t LlDistance to nearest: Well�Q-- Foundation Property Line�� ffff DISPOSAL PONDS« ❑ I 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 1 rules and regulations of the San Joaquin Local Health District. , -T 4� 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 employ any parson in such manner as to become-subject to workman's compensation laws of California." Contractor's hiring or a wookmant+scompesignature certifies the following: "I certify that in the performance,of-the work for which this permit is issued, I'shall employ persons ensa- tion laws of California." .. I The applica Ti ht must call for all required in YtionS: Comp�leta drawing on reverse side. i Signed Xi `� - r T 1 Date: FOR REPARTMENT USE ONLY Date Area ' ApplicationlAccepted by I" I Date Final Inspection by DateF� s Pit or Grout Inspection by '" Additional Comments: 4 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Menteca 823-7104 — ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave-, P.O. Sox 2009, Stk., CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED CA --::ECEIVED BY DATE PERMIT NO. .INFO n ``�, j '} l r.EH 13-24(REV.1/ns) , � t✓ _00 70 . 00 •_�`� � �� _ EH 14-26 Z