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APPLICATION FOR PERMIT tl SAN JOAQUIN LOCAL HEALTH DISTRICT � 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. e �lj �t� �4 /G� City Lot'Size5au� T PM Joh Address — �},,r �* Owner's Name r`�ry EO L — Address r Phone' ✓" { "" Contractor's Name (6�x {cense No. rSt�4 07 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ z! PUMP INSTALLATIO '❑ SYSTEM REPAIR ❑ OTHER ❑ , DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLP. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y • �: ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing $Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ pub ❑ Other"' ❑ Delta Depth of Grout Seal Type of Grout . ❑ Irrigation .s,;�4ppro DepthEastern Surface Seal Installed by Repair Work Done ❑ Type of Pum4 W.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material f Itop 50'1 � Depth 1. Filler Material {Below 50') TYPE OF SEPTIC WORK:_ NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is �~w6,41able within 200 feet.) Installation will serve: Y Residence X Commercial— Other Number of livingunits._� Number of bedroom i� Character of soto a L+ pth of 3 feet: -PA&D 0 €* t q () 6 Water table depth SEPTIC TANK j Type/Mfg 'Capacity No. Compartments UNES PKG. TREATMENT PLT ❑ �ii r Method of Disposal Distance to nearest: Well ._- Foundation 0 Property Line � LJi7'F+ IT, `" � : ! _ LEACHING LINE � No. & Length of lines `' - �f;r 40 tl Total length/size X r� FILTER BED ❑ -Distance to nearest: Well Founatio� Property Line t { * yam 4p r ` �?1 SEEPAGE PITS � Depth s^�� -^�.—Siie Number r��'T ,. SUMPS 1 Distance to nearest: Well= — Foundation a / Property Line S� DISPOSAL PONDS ❑ hereby certify that I have prepared this applicatiort and that the work will be done in accordance with San J qui; county ordinances, state laws, and rules and regulations of the San Joaquin LOcaI Health District. Home owner or licensed agent's signature certifies the following: "I ce7tlfy tha - the performance of the work for�which,this permit is issued,'l shall not employ any person in such manner s to become subject to workman's pompe satf 6 ws of California."ContractoYs hiring or sub-contracting signature certifies the following: I certify th in a performance of the work for which is p6r is issued,I shall employ persons subject to workman's compensa- tion laws of rni ." l L/�* * � The applic t st or re a spections,:Complete drawing on r de. Signed 4d �� Title: + { Date: ! _ .' FO D PA TM ENT USE ONLY ®� I44�- Appiiqt on Accepted by Date Area Pit or Grout Inspection 6y Date l Fill Inspection by � Date / '' r a rcw 644Vr � /-C A' liJn G✓tv- Additional Comma : r ' l V h Z� d a - I ❑ Stk 466-6781 ❑ Lodi 369-3821 rManieca $237 04•-x ❑ racy 835 63I s ��4 �"AL � t[ Applicant- Return copies to: Environmentallealt Permit/Serices 1601.,E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r 4T FEE T AMOUNT DUE ` "AMOUNT REMITTED #' RECE D f Y } DATE PERMIT'NO. INFO CASH + EH 1324(REV.40!83) `Z S �-. k '1t ��dZ , ��; `/ill r V 09 ,. EH 14-26 T I