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GI APPLICATION FOR PERMIT SAN JOAQUIN,LOCAL,HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON; CA Telephone (209) 466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED (Com Dy , ''..L, (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the ~! 1, made H compliance with San Joaquin County Ordinance No.549 for sewage or Na. 1862 for welt/pump and the Rules and Regufati Local Health District. it "W M work herein described. This application is h7: a "' " . �• . i ons of the San Joaquin Job Address "« ,• 3>' k�. Y ) fCi / L ,City /� �. .... i ; � Owner' Lot Size s Name PM ------- �, _ o Address- "A ddress �"" --•— .y ,, ��rt s'� Phone v jam. y Contractor eG3 a%! �_. { �� Address v TYPE OF WELL/PUMP: i License No �(� � f NEW WELL ❑ WELL REPLACEMENTPhone �— PUMP INSTALLATION ❑ DESTRUCTION ❑i D ` DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR:ID a SEWER LINES THER ❑ _ ,FOUNDATION DISPOSAL FLD. LINE AGRICULTURE WELL INTENDED USE TYPE OF WELL - OTHEF�WELL_ PITS/SUMPS PROBLEM D f ❑ Industrial ❑,Open Bottom CONSTRUCTION SPECIFICATIONS a ❑ Domestic/Private ❑ Manteca ` d J Dia. of Wel! Excavation �;%Gravel Pack f Dia. of,Well Casing l ❑ Public ❑ Tracy: Type of Casing r j '! D 4 'f14 ❑°tither ❑ Delta Specrfcations 4 ❑ Irrigation = i f bepth of Grout Seal 1 ! � -Approx. Depth Cl Ea Surface Seal Installed by { / Type.of Grout ,Repair Work Done ❑ r Type of Pump �� H.P. Well Destruction ❑ Wel! Diameter I State'Work Done s �_ ' ` `^ C Sealing Material {top 50') Depth � TYPE OF,SEPTIC,WORK: Filler Material {Below,50'I #1 f. j {NEW INSTgLLgTION ❑. RgPAIR/ADDITION I i ) f Y DESTRUCTION ❑ fNo septic system permitted if public sewer is '3 1 InstatlaVO will se e:y R sidence y t I V Commercial _ available within 200 feet.) Number of living units: ,Other. Characbeclrooms ter of ' ; �'�"��3't +f's a �,.._ soil oto a depth of 3 feet:" X71 I SEPTIC TANK ' ;❑ Type/Mfg a. _z R .. Waer.ZW depths S PKG. TREATMENT PLT. �E ` �Ca ry p } y ,yF F I,�,•..,.,,,..,r f Pact No. Com artments f 3 J Distance-to nearest:3 Well Method of Disposal + Foundation 7 r i ) Ei i Property Line LEACHING LINE No. & Length of lines` --�$��' j_; - FILTER BED �Y Total length/size 9,Q Lp�istance-to-nearest:1---.�-yyell �' ` .; Jr' I Fiiuniiatlon $ Property Line SEEPAGE PITSpihs X Size j✓s' SUMPS L&!Distance to nearest: Weil t?• Number DISPOSAL PONDS ❑ �undation ---Property ine � pI hereby certify that! have prepared this application and that the work.will-be, in accordance with San Joaquin county ordinances rules and regulations of'the.San Joaquin:Local,Health District._p " t Home owner or licensed agent's signature certifies the followin �` y 4 h° state laws, and employ any person in such manner as to become subject to workman's compensation laws of California.`"Contr 3 g: '9 certify that in the performance of the,wo�k for which this p6rmit is issued, l shall not certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall em to tion laws of California." actor's hiring or sub-contracting signature p f}�persons subject to workman's compensa- The applican st call for a!I requir ins D pections. Complete drawing on a rse side. � � Signed "� Title: ! Date: FQR DEPARTMENT USE ONLY Application Accepted Date Area ��Pii or Graut Inspection by ~� w Date — Final Inspection by Additional Comments: Date ❑Stk 466-6781 ❑ Lodi 369-3621 ❑,Manteca 823=7104 �' ❑ Tracy 635-6385 F Applicant- Return all copies to: Environmental Health Pemit/Services 1601 E. Hazelton Ave„ P.D. Box 2009 .'Stk:, CA 95201 , . 1. r INFO` "' °MdUMT pUE--w- ^AMOUNT-REMITTED F CK_# .,,,, CASH RECEIVED 1311111-- —RM . _�.- �-�- ---�-* EH 13-24 iREV.I/s si ATE-y s PERMIT NO. EH 1428