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APPLICATION FOR PERMIT SAN .lOAQUIN LOCAL HEALTH DISTRICT D 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . Hltp,�SH (Complete in Triplicate) EN4 , NVIRCM RVICES Application is heieby made-to'the San Joaquin,Local Health District for a permit to construct and/or install the work herein application is made in compliance with San.Joaquin County Ordinance No.549 for sewage or No:1B&2 for welllpump,and the Rules and Regu ations of the San Joaquin Local•Health District: . ; .F 1 (At?. � .. ..rC1ty;,.w, .,.,. Lot Size �.PM-. o de u 14n Job Address _ - 1 ' Owner's Name L IV s� __ 1 address -1' D '� '?� Z-3]] 0 & A-- Phone Contractor Address 7 a? License No. l-��Z�Fhone D TYPE OF WELL/PUM . NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INE TALLAThOnnN��77❑) � SYSTEM REPAIR ❑ OTHER ❑ px�� DISTANCE TO NEAREST: SEPTIC TANK —Lim SGcWER LINES DISPOSAL FLD. 100 PROP. LINE ZYC2_ a_:, _ _A �:, ..� L . .�-._.f-- .__ .- _ �'��''' ' FOUNDATION AGRICULTURE WELL ,� OTHER'WELL.�__— PITS/SUMPS �i 7t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 5y:i ! S' 4f, ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation `' Dia ll'4 Well Casing, .is q t Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �fll k M Public 11 Other l Delta Depth of Grout Seal _ SO ___ Typeyof GroutS'� _, I I irrigation WApprox. Depth I Eastern Surface Seal Installed by _ _ nj .w Repair Work Done ❑ Type of Pump••••-�--_----•�-' -�-#i-R.. _--State State..Wark_Done __ Well Destruction._ _❑WeII.DiametSeling=-Material{ ) `A W Depth Filler Mater' Below 50') t f TYPE OF SEPTIC-.,WOFtX•'%:NEW�INSTALLATION 1.1 REPAIR/ADDITION 1 1= DESTRUCTION I I.(No septic system permitted if public sewer is 11 available within 200 feet.) frO " Installation will serve: OIesidence_ Commercial_ Other t` Number of- iving u0s:4 Number of bedrooms I ! 4 Character of soil tojadepth of 3 feet: Water table depth I I SEPTIC TANK ❑ Type/Mfg # Capacity No. Compartments .� PKG. TREATMENT PLT. 0- _ Method of Disposal t Distance to nearest: Well Foundation Property Line L LEACHIIVG�L.INE �Pf t,CY'l No. & Len of lines Total length/size j FILTERq§ to nearest: Well, Foundation Property Line ) SEEPAGE-PITS.. I I epiii Size, A Number SUMPS n Distance to nearest. -Welt ; Foundation-- ^Property Line DISPOSAL PONDS 0 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, $tate laws, and rules and regulations of the San Joaquin Local Health District! I i Home owner or licerssed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person inr'suc6 manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the folioviiiiig: "I certify 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 Califo ia." i The applicant m t all for-all required inspe tie mplete rawing on reverse side. p Signed X 1 Title: /l.dt� Date: 1��a FOR DEPARTMENT USE ONLY APP12ati r A�cepted�by" -"-�----.r._„`..' "Date.J(C�D7 �� _ Area 06 y Pit or Grout Inspection by Date 7 Final-inspection by-- Dat I� Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEECK*I [ INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0.k ', 4 s j.a EH 13-21 IREV.1 5 ` EH 14-28