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i! I ^' APPLICATION FOR PERMIT SAN JOAGUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTONa"JE.,,STOCKTGPl, CA Telephone (209) 466- 6781 f PERMIT EXPIRES 7 YEAR FROM DATE ISSUED (Complete in Triplicate) Appiicetion is he:oby mode to Iho San Joagvin Loca:Health District for a permth to ronstruct and/or instal!the work herein described.Tin,application is madu in mmplianca with San Joaquin Count,Ordinance No.549 for sewage or No ID32 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. n Job Address �,�_�J / L/� 1J 'J VJ-. V 5 _ City.Z�- Lot$ire J W_L.Z_ �— PM ii _PM-- ii We Name 4 �- Jill L�t�2 I L2'��_.._ �-,/�—'�/ ..rias i,I�.JS[/SJ 1J�:i�! GOf7 ,7 C) �—_ Phone �?� ' L�� r? I G I Con trartor__.� �� Address._ =____ If License No. -- Phone ---- TYPE Of:WELL/PUMP: NEN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 DISTANCE TO WEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL___ PITS/SUMPS Q' INTENDED USE TYPE OF'ATI-L PROBLEM AREA CONSTRUCTION SPECIFICATIONS x — _ � ;i Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia.of Well Casing y G Domestic/Private G Gravel Pack D.Tracy Type of Casing_ Specifications ❑ Public (I Other ❑ Delta Depth of Glut Seal Type of Grout- 0 Irrigation —Approx, Depth 0 Eastern Surface Seal In9talled by Repair Work Done 0 Type of Pump __ H.P.- rI State Work Done _- - Well Destruction ❑ Well Diameter -. - Szalmg Malcriai rtop 50') ,f t Depth ,' Filler Mattncl (Below 5r TYPE OF SEPTIC WORK: NEW INSTALLATION 4_ REPAIR/ADD TION LDESTRUCTION ❑ (No septic system permitted f Public sewer is available within 200 feet.) 7 Installation will serve: Residence__ Commercial_X Other__ ` ) w Y Number of living units:____ Number of bedrooms �i t Character of soil to a depth of 3 feet:._. z � Wutartable l SEPTIC TANK ElType/Mfg (J L t,- apacity__ No. Compa9ments a• ` I 1tt1 PKG. TREATMENT PLT.❑ !� ��nn �4 / P cihod of9Dnisposal _I Distance to nearest: Well�v r Fourdatiolo J /� Propert _inn ! LEACH:';G LINE No. & Length of lines _ 4 ) lengthrs:ze__�� :?S FILTER BED G Distance to ncarost: Well� ro Foundation�� __ Property Line .. `. SEEPAGE PITS G Depth --Size—= Number ____ r•,'� SUMPS G Distance to nearest: Well_ Foundanor Property Lin:. DISEl . _ ,.j DISPOSAL PONDS tT V- I 4 I hereby certify that I have prepared this application and that the work will be donein accordance with San Joaquin county;ordinances,state laws, add t .b� rules and regulations of the San Joaquin Local Health District \\�\ } Home owne•or licensed agent's signature certifies the fallowing: "I cert fy that Ir die performance of the work for which this permit is issued. I shall not 1 iI( employ any person in such manner as to become subject to workman's comoersanrnv law-or C!Hernia"Contractor's hiring or sub-contrac.ing signature certifies the followings"I ceri y that in the jya forma nice of the work for whrcr m..poen t Is mu•.1,I cha 1 employ persons subject to workman's ccmpensa- j tion laws of California." /) j t The applicant m�s' cn11 to 11 rag uireed�jic�s.Tfo ns. Comoteze draxvin orvrs eras s�idu.� Signed X �"tr1�T/ ( I " T -- Title: Y; =J_Q _ Date: FOR DEP MENT USE ONLY 0-7 .,j Application Accepted by ...� Date.? �� /�kJ Area t Pit o. Grout lbs cti�on t r _ - Date Final9nspeection by '� Data_ ?,Ml i�C— mss{-cl/¢-/-t•— /,.,oS r .hL � �'.'cI /tpsW / '^.S,aPr wrG'tC.•�a...T�c. �„a„t,se.� /r-q) E Additional Commert. A / G SO, 466-6781 ❑ Lodi 369-3621 ❑ Manteca 621-71041 Trscy 835- 1 Applicant Return all copies to: Environmental Health Pcrm t/Sorvirms 601 azplton Ave., P.O. Box 2009,Stk., CA 95201 IJ) FEE gMOUNT DUE =MOUNTREN11=0K"CASH i) Rt ChIEDaY DAT'[ PERMIT N0.MFDEH 213.reEv.1'a 1;� ��= Iv fH 1415 — r i� 1 'i _ _ q