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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 4,66-6781 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 compiiance with San Joaquin unty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rule,and Reaulaticlns of the an Joaquin Local Health District. lJ. 1/ jQ 3 o y� t X02 Void, _..�z� C� Job Address _ _�1��/�_ � _L' ttty ----- Lot Size lZi �., r r'1 - PM Owner's Name -. 7 � _ Address lL y� L•LL/ '1 _ �/ Y. h.ne Contractor. lO��_Address l[ense No. P_h_on!e - 1 _ TYPE OF WELL PUMP: V NEW WELL WELL REPLACEMENT L] DESTRUCTION Ci PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OrHER D DISTANCE TO NEAREST: SEPTIC TANK -110t)e, SEWER LINES DISPOSAL FLD..&,)J1C PROP. LINE- ----- FOUNDATION INE__ FOUNDATION -- -. AGRICULTURE WELL _ OTHER WELL—— PITS%SUMPS _ 'NTENDED USE TYPE OF WELL�PROBLEM AREA CONSTRUCTION SPECIFICATIONS Y` Industrial ❑ 0 — rr Open Bottom ❑ Manteca Dia. of Well Excavation_— Dia. of Well Casing Q4 Domestic/Private 04 Gravel Pack W Tracy Type of Casing —.�� Specifications aa I/L.. M Public Cl Other M Delta Depth of Grout Seal �L' _ Type of Grout i/(-/tilt'LL.. I I Irrigation _-Approx. Depth t I Eastern Surface Seal Installed by dut1 L.a:� Repair Work Done D Type of Pump _—_— H.P. _ _ State Work Done Well Destruction ❑ Well Diameter _.._ Sealing Material (top 50*) Depth Filler Material tBeiow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I : INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence__-- Commercial-__- Other Number of living units: __- Number of bedrooms Character of soil to a depth of 3 feet —_Wirer table depth SEPTIC TANK ❑ Type/Mfg -� Capacity-------- _ No. Compartments PKG. TREATMENT PLT. Ci Method of Disposal Distance to nearest: Well_ Foundation Property Line LEACHING LINE L7 No. a Length of lines _-- Total FILTER BED ❑ Distance to nearest: Well Foundation _-._. Properly Line SEEPAGE. PITS I I Depth Size Number -- SUMPS L.i Distance to nearest: Well - Foundation Property Line_ DISPOSAL PONDS 11 I hereby certify that I have prepared this application and that the work,will be done in accordance with San Joaquin county ordinances, state taws, and rules and regulations of thy San Joaquin Local Health Di vict. Home owner or licensed agent's signature certifies the following: "I certify that to the performance of she work for which this permit is issued, I shalt not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following- "I certify that in the performance of the work fop which this permit is issued, I shall employ persons subject to workman's compensa- tion iews of California." The applicbL ust call for all requirn/spections. Com late drawing nn r side. Signed X dC ACC 7it{e' L. t.( t Date: R I AR ENT USE ONLY f D Application Accepted by __ Area — c -s�/ _ �d _ _ Oate Pit or Grout Inspection by Date _ Final Inspection by__ Date Additional Comments: J Stk 466.6781 ❑ Lodi 369.3621 ❑ Manteca $2,T 7104 — ❑ Tracy 835-6385 -- — - -~-- ----_Y Applicant • Return all copies to: Environmental Health Permit/Services 16R11 E. Hazelton Ave., P.O. Box 2009, Stk., CA x,201 FEE AMOUNT DUE AMOUNT REMITTED INFO L V.A rl YRECEIVED By - DA)TE. PERMIT'NO. ..EMt}2r1REV.i/nsi r / 'l0`7 � (t..�1� _(�.. - EH 14 26 1..1:`