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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEILTON AVE., STOCKTON, CA Telephone (209) 466.6781 'r LO .3.—Jt. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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.1882 for well/pump and the Rules and Regulations of the San Joaquin Local Health District., * L Lr + ',r Job Address City Jaewntf "ot Sae PM Owr�rs Nana ��2� e 1r-5/ A�aana.. 2 33 sa N f Phone 6 10 20 Contractor's Name se No. Pho �aa7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE —% �. FOUNDATION.' AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ti- . -Manteca+ bia'bfNJell'Excavation Dia. of Well Casing• of Casir T"e i Specifications 1 ❑ Dorrleatic/Private ❑ Grovel Pack t' C1 cry YPe A Tre ❑ Public ❑ Other. -` ❑ Del Depth,of Grout Seal Type of Grout y ti0epth ❑ Eastern" —Surf re iBs I Installed by ' 't ❑ Irrigation - —Approx- •. ,F§_ Repair Work Done ❑ Type of Pump -"• H.P. J` State Work Done Well Destruction ❑ Well Diameter t Sealing Materiel (top 50') ` U1 Depth " Filler Material(Below 501 d TYPE OF SEPTIC WORK: NEW INSTALLA ON ❑ REPAIR/ADDITION ❑ `DESTRUCTION O tNo septic system pennitt public sewer is N available within 200 feet.l�d Z Installation will serve: Residencal Commercil_Other Number of Bving units:—t Number gf.bsdreome — t•, i `' 1 Character of soil to a depth of 3 feet: `t"`` 1 Water table depth (�I 1.. SEPTIC TANK I]iType/Mtg i� apacity C _. lXG.^—,.� )i Compartments -2 � : � v / PKG. TREATMENT PLT.❑ 1 - 11 Method of Disposal Disro to erest�""�ell—��j= Foundation Property Line L LEACHING LINE H No. & Length of lines FILTER BED 2,�Distaitce to nearest: Well, t� FoundaYronj-t ' �F'roPertY Line l('' Y, SEEPAGE PITS -f<,Depth —2,�7_2Siza �r,{�- Number 17 �--- SUMPS Distance to st:neare 'Wall � a Z � Foundation Property Line DISPOSAL PONDS ❑ 1 1 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 regulations of the San Joaquin Local Health District. Home owner or licensed agents 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 manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting 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 California." , The applicant/Mdust call for�I r�Pred inspection . Complete drawing on reverse side.. -Signed Y V/� ^� CJ7/ 164 Title: ✓ - �s Date: 0 - FO DEPARTMENT USE ONL Application Accepted by .,.Date 7-- Area Pi r Grout Inspection by ., !i ) ate i Final Inspection by Data Additional Comments: - ❑ Stk 488-8781 ❑ Lodi 369-9821 O Manteca 823.7104 ❑ Tracy. 8364MM Applicant - Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 98201 FEE gMOUNT DUE € AMOUNT REMITTED CABH REGENED BY DATE PERMn•'No. � INFO EHt}N Ill 10/431 ' EH 1426 - -