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APPLICATION, 1.FOR PERMIT SAN JOAQUIN';LOCAL HEALTH DISTRICT 1601 E. HAZELT'ON AVE., STOCKT_ON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR,FROM DATE ISSUED. r. ,r�nJr,:.. r:�rr.' _ . ;�"r : . V . : tjj._;. (Complete in Triplicate).:. 4r C.fl--Y orG J�e-C-d7-S 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. T ' VW tt� l# ' .i f) r . % art Job Address *� 1 GJ / /7�l I� City Lot Size .7 /�GG��PM ((( Owner's-Name- Address _667 f fr /,r __Cr_ Phone - _'Conftactor's Name License No. Phone T TYPE OF WELL/PUMP:, t NEW ELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ PUMP INSTALLATION ❑ i SYSTEM'REPAIR O OTHER ❑ } DISTANCE TO NEAREST: SEPTIC TANK `' SEWER LINES g DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL) I. FOTHER-V11ELL7 > PITS/SUMPS INTENDED;USE TYPE.OF WELUy PROBLEM AREA CONSTRUCTION SPECIFIC4710NS f ❑ Iridustriai El Open Bottom's ❑ Manteca Dia. of Well Excavation I _ Dia. of Well Casing ❑ Domestic/Private ❑ Gravel:Pack F '' 'ETrac Type of,Casinw �- } y yp f g Specifications ❑ Public ❑ Other ❑ Delta Depth of GrOut,Seal_,!�'4;'"=Y' ° o Type of Grout I ❑ Irrigation �4pproxe-Depth—j Surface'Seal-Installed y Repair Work Done ❑ Type of Pump H.P. State Work Done • . - WeIIZDes ruction O_ Well Diameter _ Sealing Materia! ltoo 501) ,:Depth i ` Filler Materiallielow 50') t TYPE OF.SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ fNo septic system permitted if public sewer is # available within 200 feet.) Installation will serve: Residence! Commercial I�/Other s'-�^�� A �e Number of living units:—6 Number of bedroo s J M r I Character of soil Jo a depth of 3 feet: Water table,depth �P SEPTIC TANK - X,Type/Mfg Capacity for No Compartments PKG TREATMENT PLT:'0 �I �l 4�_ 4, Method of DisposalIs { Distance to nearest:) Well yrs Foundationx Property>Line f LEACHING LINE X No. & Length of lines Total length/size 1. r FILTER BED T'"' 11 ji Distance to nearest:' `Well r Foundation ' ProperEqll_i ne SEEPAGE PITS Xi Depth ~� Size4 � F Number, r P_ . /rte SUMPS .O Distance to nearest: Well/Q4 Foundation e Property Line DISPOSAL PONDS sr'. . ❑• � ) � 4 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 regulation's 66heSan Joaquin Local Health District. Home owner or licenser 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.rnanner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this-permif is issued, I shall employ persons subject to workman's compensa- tion laws of California." Thea pplicant must call for all required inspections. Ca tete drawing on reverse si e 4 � � _ (Signed ` ~; Title: I _ Date: � l�&s` f _ FO EPARTMENT,U ONLY 'Application Accepted by �- i Date / '" rea Pit r Grout Inspection by Date Fina Inspection by ate i` A ditional Comments: - Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 — ❑ Tracy-835-6385 A t ' -Apple Return all copies to: Environmental Health Permit/Services 1601 E. HazeltoGve., P.O. Box 2009, Stk., CA 95201 ry "fir'^- FEE"' .AMOUNT"DUE"""'—,4liA0UNTAREMI7TED"'">"�`��K� �"""RECEIVED BY � DATE 'F PERMITN.p. INFO. f ; A .:� +EH 1324(REV 10183) EH 14-26 _ d ,' �;y� - ..�e6iil�Sldi