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APPLICATION FOR PERMIT �. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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. 1862 forwelb'pump and the Rules and Regulations of the San Joaquin Local Health Drsuicl. n /n/J1� �-1 �� /S3CLs>E e�L�AV yCGc�_ — Job Address [y Ch nnn(nr�� 1Lo�t,S(ize�.�Q- PM � 1 1 500 K� WlWAY1 Phone l Owner's Name Address ,ypdA1 f 77 0 Contract tlress��7jo� ` rLicense NocD2 -- Phone X08 Sl 0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. —PROP. LINE f - - - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications I"1 Public ❑ Other fT Della Depth of Grout Seal Type of G /Mig rout_ o 1 1 litigation —Approx. Depth 1 I Eastern Surface Seal Installed by _ Repair Work Done El Type of Pump H.P._ State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is ^. available within 200 feet.) p Installation will serve: Residence✓ Commercial_ Other 0 Number of living units: --L— Number o ro�ofis Character of soil to a depth of 3 feat: / lY�A. Water table,depth SEPTIC TANK Type _ �f Capacity -6n No. Compartments r PKG. TREATMENT PLT. El / f 1�^�kf Method of Disposal Distance"to nearest: Well_,Z8 Foundation 1t.2_ Property Line .vim "An LEACHING LINE No. 8 Length of firms neIota[length/size Q X FILTER BED ❑ Distance to nearest: Well .SO Foundation 10 Property Line S 1L/_ SEEPAGE PITS IA Depth Size q: , 'zs.Number SUMPS 0 Distance to nearese Well 1110 -! Foundation 16 Property Line DISPOSAL PONDS ❑ ` I hereby cenify that I have prepared this application and that the work,will be done in accordance with San Joaquin county mdinarrces, stale laws,and mica and regulations of the San Joaquin Local Health District:, I Home owner or licensed agent's signature rwrtifies the fofiowing,7 1 certify that in the performance of the work for which this perms 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,1 shall employ persons subject to workman's compensa. tion laws of California." The applicant¢\�(s\t c.�all for re orad inspections. Comdata drawing on reverse side. Signed Title: Dae: 15 T /,1 1,8p FOR DEPARTMENT USE ONLY / ��' /Application Accepted by ' Oatry ��/��[2 /� Areal y rp or Grout Impaction by Date�. 5� Final Impaction bV-A A"�y— Date Additional Comments: ❑ Stk 466-6781 0,Lodi .369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-fa`189 r Applicant- Retum all copies to:Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009. Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DMO r EX Illi IREV.v n at O 1 EH t1]E YW ��