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Y� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT _ + 1641 E. HAZEL i ON AVE., STaCKTON, CA Telephone.(209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Cl rnplete in Triplicate) t to all the work is cation madle-AppiC n ion is herby wr h SanoJoaqu nthe SanCounty O d Hance NJoaquin Local th District for a o.549 for sewage or INo 1862 forcwell/pump atnd the Rul s and IR gulations of tthe Sanl Joaquin is Local Health District.�j City +0 e-O Lot Size 9-0 )K, 0 PM Job Address w 517 Owner's �� ddress �� MI /e I r Phone T Owner's Name {� 5:-e/ . Address Contractor License No. Phone NEW WELL ❑ WELL REPLACEMENT❑+ -DESTRUCTION ❑ TYPE OF WELL/PUMP: * , c PUMP INSTALLATION LD 4 SYSTEM REPAIRtO xr� OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom' ❑ Manteca Dia. of WWI Excavation Dia. of Well Casing © Domestic/Private ElGravel Pack,.' - L] Tracy Type of Specifications ❑ Public FI Other ❑ Delta Depth of Grout Seal Type of Grout — . ! I Irrigation --Approxi Depth l 1 Eastern Surface Seal Installed by Repair Work Done L] Type of Pump H.P. r State Work Done f : Well Destruction ❑ Well Diameter Sealing Material Itop-50Jt ' a Depth a Filler Material (Below 50•) t TYPE OF SEPTIC WORK: NEW IN5TA LATiON €:I REPAIR/ADDITION I 1 DESTRUCTION INo septic system permitted if public sewer is i available within 200 feet.) Installation will serve: Residence Conmercial L Other—�•------- - --_ - -� Number of living units: Number of bedrooms r Water table depth Character of soil to a depth of 3 feet: x ''Capacity' No. Compartments ' SEPTIC TANK ❑ Type/Mfg �" - I PKG. TREATMENT PLT. ❑ , t", Method of Disposal \ Distance to nearest: Well Foundation Property Line +\'� LEACHING LINE ❑ No- & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ` SEEPAGE PITS l I Depth Size Number "SUMPS [3 Distance to nearest: Well Foundation Property Line ' DISPOSAL PONDS L7 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 rules and regulations of the San Joaquin 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 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 cgxqy 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 California." The applicant st call o all required inspections. Co lete drawing on reverse side. ! n�, _ Date: I Lr-Z-7— 11-77 ?: v Signed X Title: _�� f . �r FOR DEPARTMENT USE ONLY Applicati ccepted by . Date Area j Pit or Grout inspection by Date Final inspection by Date a f � Additional Comments: ❑ Stk 466-6781 E) Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 If Applicant- Return all copies to:.Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK5H RECEIVED BY DATE PERMIT NO. INFO + EH t3-24 rREV.t i 851 � EH 1428