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S APPLICATION.FOR PERMIT k SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. ,HAZE T ON AVE., STOCKTON- CA Telephone (209) 466-6781 .+.. 8 PERMIT EXPIRES.1 YEAR FROM DATE ISSUED �:: i •_i �xs, :a:... 1i:31"+.�'? >r3,,(Complete in Triplicate)-,-j 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;. i'c. 1'1"o VrJ t fir a��x '} nn,r�;�€ � r Job Address 2 � G �Y '73 '" - City _._ Lot Size S PM Owner's Name �'� p�r��}'S T� Address '� _may 141��' �-3 Phone � t ` -TYPE Name,. � >�O� - 5C-V License No. Phone TYPE OF WELL/PUMP—: NEWIWELL,❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ , e PUMP INSTALLATION D —SYSTEM REPAIR ❑ OTHER ❑ t _ DISTANCE TO NEAREST: SEPTIC TANK SEWER ' LINES ' DISPOSAL,FLD:, PROP. LINE FOUNDATION AGRICglLT:URE WELL I OTHER WELL_ PITS/SUMPS INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS I i ❑ Industrial"" ❑ Open Bottom ❑ Manteca --=Dia?of Well Excavation Dia. of Well Casing ❑ Domestic/Private 71 Gravel Pack ❑ Tracy Type of Casing'' _ Specifications d: El Public ❑ Other .❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Purnp H.P. State Work Done j 1 Well Destruction ❑ Well Diameter Sealing Material (top 501 00 Depth Filler Material (Below 501 tt TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION0 DESTRUCTION ❑ (No septic system permitted if public sewer is d available within 200 feet.) Installation will serve: Residence L Commercial_ OtherI, �.rcial Number of living units: Number of bedrooms Character'of soil to a depth of 3 feet: Ae.4,v Water table depth SEPTIC TANK r ""-W Type/Mfg /�y�=C� T• Ceic.e. Capacity -0" _ No. Compartments PKG. TREATMENT PL-T:El r I i 11 Method of Disposal 47 �t 01. } Distance to nee arest: 1Nel! -�✓`_l'y Foundation �� Property Line LEACHING LINE ❑ No. &'Length of fines Total length/size ' "-"FILTER BEDI SIS Distance to nearest: (Nell 25�3�. Foundation 2 -P Property Line SEEPAGE.PITS ❑r; Depth Size Number s�aSUMP5� ❑ D€stance-to nearest "—Well Foundation==:±: �----•Property Line DISPOSAL-PONDS. µ I hereby certify that'l have prepared this apOication and that the work will bg done 674ccordanca with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature•certifies the following: "I certify that in the performance of the work for which this permit-is issued,.l shall not employ any person in such manner as,to became subject to workman's compensation laws of California."Contractors-Miring or sub contracting'signature certifies the following:"I certify that'in the performance of the work for which thispermh is•issued,i shall employ persons subject to workman's compensa tion laws of California." '" The applicant mus'"call for,41 required'inspections. Complete drawing on reverse side. tSigned Title: �i Date: �,ii-gs� F R DEPARTMENT USE ONLY �g .a t. i. B 3� on Accepted by 1 ` Date_ Area Applicati Pit or Grout Inspection by Date Final Inspection y Date�� � Additional Comments: ° ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ anteca 823 71 C3 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 € IFEE' / MOUNT DUE AMOUNT REMITTED CASK RECEIVED BY DATE PERMIT"NO. INFO w +EH 13-24 IREV.10!83!✓ �j� ^��—t O EH 14-26 �y f