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f. I li APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone =914W6781 Il s'%PER1OilJEXPI�,'f YEAR FROM DATE ISSUED (Complete in Triplicate) F Application is hereby made to the San Joaquin Local Health District for a permktto construct and/or install the work herein described.This application is made in compliance with Sen Joaquin County Ordinance No.549.for sewage or No.1862 for well/pump and the Rules and Regulations of the San Joaquln Wcal'Health District. y' Job Address !CJ.3e)1 K • " City Lot Sire r PM Ovmt:r's,Nam ��rr e /V►`ClC 1`��$.�. _ Address —19 301 Al-_��hQ.- Ph,,:2 'SI i 4 Contctor s-Nana 3Licerise No.. .,�`1 / 2= - Phone 1 Y4--E- F:W.ELW.P-UMP:-- -:....Y-NEWWELIr- .- —'".ELtf-REPLACEMENT'Q -DEST•RUCT40N-0 - 1JMP,IiJ�TALLATtON 13 _ .SYSTEM.REPAIR ❑ 4 OTHER M— DISTANCE DISTA,NCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 2�= PROP. LINE 9' FOUNDATION ��---•AGRICULTUREW-ELL. OTHER WELL, PiTSISUMPS,�-- (N ENDED-U5e TYPE 6r WELL PROBLEM AREA CONSTRUCTION SPECIFICATION q 0 InidWtrisl `. pen Bottom :E] Manteca 7:j i rf Oiti:,of Well Excavation ` ' Dia. of Well Casing pr Domestic/private 1-.❑.G a�el"Pack D Tracy Type of Casing' r 1 Specifications ► �Z .I-C-.+ -a.' O Public f�'Othar p_Delta•.Depth pI Grout:Seal Type of Grout t ❑ Irrigation 'ZQLApprox:Depth 0 Eastern Surface Seal Installed by 1 Repair Work Done ❑ Type oYPump H.P. State Work IN jtir ' i F Well Destruction! ❑ Well 13,141. �� Sealing Mate' ep 56'1 Dep Filler Ma I (Below 501 ✓ TYPE OF,SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ 1No septic system permitted if public sewer is r available within 200 feet.) installation will serve: Residence— Commercial_ Other • or r -` Y Number of living'Units: Number of bedrooms I W Character of soil to a depth of 3 feet: star table depth SEPTIC TANK C3Type/Mfg# Capacity o. Compartments PKG. TREATMENT{{{{'PLT. ❑ , Method of Disposal ? y Distance to nearest: Well 'Foundation Properey Line L rr s 1 LEACHING LINE 0 No.& Length of lines Total length/size FILTER BED ❑ Distance to nearest: Welty I Foundation Propel Line :S> W SEEPAGE PITS ❑ Depth F ' Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line �{ DISPOSAL PONDS ❑ 1 O] I hereby certify ttot,l_have_preparedANs,applicatlen.and-that••the-work-will•be-done-irraccordance-vvkh•-San Joaquin county ordinances,-state laws, and rules and regulations of.ths San Joaquin Local Health OiWict„t i Home owner or licensed agern's signature certifies the following:"'t-certify that in the performanoe of the work for which this permit is issued,I shall not I employ any person in such manner as to become subject to workman'p 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 permlt is Issued,I shall employ persons subject to workman's compensa- tlon laws of Callfornla:'.' .rt The applicant ci31i fay all fired n Ions. Oomple'le' awing on rreevi-se slda. Signed . ,,� ' dClIe:�Y' N t � .�^ .> lt�` � --•�-• -Date: FOR DEP MENT U ONLY1.j"`i:�_ ✓`��.tv ,c / Applicstio opted by Date roe 1l J Pit Grow pection.by ate -fy Final Inspection by Date { Additional Comments: 0 Stk 4866781 0 Lodi 3821 V ❑ Manteca 823-71D4 0 Tracy 5-ff385 i Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hezalton•Ava., P.O. Box 2009, Stk., eqL1 t INFO AMOUNT DUE AMOUNT REMITTED CCASH RECEIVED BY DATE PERMIT"NO. E }� 4 (RECH 11V•,7018;1) 28 J-