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• A APPLICATION.FOR PERMIT SAN JOAQUIN;LOCAL HEALTH DISTRICT 1601 E. HAZELTOWAVE., STOCKTON, CA Telephone (209) 466-6781- y tZ l r I `°1 l IC zirj;011,: 10 PERMIT EXPIRES - EAR FROM DATE ISSUED }�$ ' it'a ."=fid 1' . nx..vo t),fjaf?t ''tt:._IComplete..in�Trlplicate}�...,,fi.;�s"Sarfokle.)O J.iB' ,ir�r�i'yCrc7iw';+ I r ' 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,.,1$62 for"weli/puman p, d the Rules and Regulations;of the,San Joaquin Local Health Distract ,r''.c�'x ,:? tC,.7 c= e ;fs , .3t..<:. . ;tft5 a 1" r . ,_ y w 'tr•. J,,IrJJa.lts (�E"�, �Z7 r1firl,;f �.�?t9 �• t,��:�la": City Lot Size Job Address /2 15- Lf4Ii GL! - _ "�� PM Owner's Name Address _� '' -' Phone - — Contractors Name a f License No. Phone TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ -SYSTEM'REPAIR O." OTHER ❑" DISTANCE TO NEAREST: _SEPTIC TANK SEWER'S LINES �'DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL __L__'OTHER WELL" PITS/SUMPS = \ INTENDED USE TYPE OF WELL: PROBLEM AREA CONSTRUCTION SPECIFICATIONS% ❑ Industrial ❑ Open Bottom Q Manteca t_Dia. of Well_Excavation, pia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of"Casing M Specifications ❑ Public ❑ Other ❑ Delta' Depth of Grout Sea! Type of Grout ' O Irrigation --Approx. Depth ED Eastern surface Seal Installed by t Repair Work Done D Type of Pump H.P. State Work Done Well"Destruction ❑ Well-Diameter S.Baling Material (top 501 Depth i Filler Material (Below ), r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ 'REPAIR/ADDITION. DESTRUCTION ❑ INo septic system permitted if public sewer is available within"200 feet.) 1 Installation will serve: Residence 1'�~_Commercial Other Number of living units: '—'Number-of bedrooms_-3— Character —3 -Character of soil to a depth of 3 feet: —1Q 7t�1 _ Water table depth &0 I r ' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line - LEACHING LINE ❑ No. & Length of lines Total length/size U FILTER BED ❑ -Distance to nearest:" Well �o Foundation /v Property Line 6Alit N SEEPAGE"PITS Depth Size 1 Number ,LI SUMPS I-] ' Distance to nearest: "Well ' ' " 'Foundation" ' - Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,'state'iAvs, and rules and regulations of the San Joaquin Local Health District. .• Home owner or licensed agent's signature certffies the following: "I certify that in the performance of the work for which this permit is issued,.lnha!! 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 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 Calif9rnV The applicant call r" d`inspect' s. C plate drawing 6n--reverse side. t ` Signed X Title �f� -ate Date: . .. FOR DEPARTMENT,USE ONLY w F Application Accepted by _`+ sown,aMw Date14 Area " 1?t.or'Grout Inspection by f Ll •37 � �t�ate__ `7rw17u S� Final Inspection by a •c],� i�,,,sai ��ts Y"e� Additional Comments: _ ❑ Stk 466-6781_ ❑ Lodi "369-3621 ❑ Manteca 823-7104 ❑Tracy 835-6385 a Applicant- Return all copies to. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,,Stk.,.CA 95201 s I FEE "^* AMOUNT DUE' . "AMOUNT REMITTED"" CK '"RECEIVE15BY_'"_'r_7DAT'Erw—`� PERMIT`NO7"_ INFO CASH +Eli 13441 4116 lkS'3S,S i EH W26 w 'J✓ ti4