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APPLICATION FOR PERMIT SAN JOAQUIN'LOCAL HEALTH DISTRICT r 1601 E. HAZETON AVE., STOCKTON, CA -Telephone(209) 46 Lee PERMIT EXPIRES 7 YEAR'FROM DATE ISSUED (C6mplete'in Triplicate) •"v�',._ h_ .y`�• i is .: - UId1r:I.C_t�_'^s.... .• ,. . RW Li , lilnao10. 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.54S for sewage or No. 1802 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. . ?'7 Qr r ..m� .. t�.�,,Cr1`/..1: '!]I v!•+. tO , : Y' 't. 'C - .y . . ' _,Job'Addressr%1 +' y� (��,[`)'7`�^: '�^' �° '` City '°'y"Lot S PM 7 rl,.�l r �1yt,,.`r/.,,,/�/ a . .. _ )ly :�, .:. :. r... t,,- �. Owner's Mania � � -/%% . Address /o-_ - �. - Phone - Contract �•Address • License N1r3�o��O� •' Phone , TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP. UNE f _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL -• PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom . rO Mentecii �,DW of.Well Excavation Dla. of Well Casing 11Domestic/Privato ❑ Gravel Pack ❑Tracy r Type of Casing'- Specifications D Public - ❑Othei "' 'L7 Dery �" '�ipih of Giqut'Seel �- 'Type of Grout.___ C Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed W Repair Work Done ❑ Type of Pump N.P. State Work Done Well Destruction ❑ Well Diameter Sealing Materiel Itop-W) - N1 Depth iI r Material (Below ,) "1r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ EPAIR DDITION DESTRUCTION O (No septic system permitted if public sewer is 6 ._ — ' , available within 200 feet.) Installation will serve: Residence-10 Commercial_ Ott g FJ'z_ _ Number of living units: Number of be rooms Character of soil to a depth of 3 feet: . - .rte.-��( �J7N "('�- Water table depth SEPTIC TANK ❑ Type/Mfg ---J6` ✓ _ _ Capacity— No.-Compartments; PKG. TREATMENT PLT.❑ _ Method of Disposal Distance to nearest: Well Foundetlon I Property Lim LEACHING LINE 9;�No. 0 Length of lines -' Total length/siz ! FILTER BED ❑ Distance to nearest: Wall Foation undPiopa-tr { / SEEPAGE PITS ❑ Depth 'Sim Number . • SUMPS ❑ Distance to ngest Wei Foundation Property Line DISPOSAL PONDS ❑ i I hereby certify that I have prepared this application and that the work w81 be*done in accordance with`San Joaquin county ordinances, state laws, an " rules and regutations of the Sen Joaquin Local Health District. Home owner or licensed agent's 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 menner 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 workmen's comperes- tion laws of Calrprnia," The applican st call for req red inspections. Complete drawing or reveres sid tt((\\trgqu\u\ - - .7977 Signed % �1 YN' Title: r</i/ . • ' - 0 OF „Data: �/J•J } FONLY Application Accepted by � � D ata" `.2- S AM Z Pit or Grout Inspection by Date_. _. Final Impaction'tiy_' Data Additional Comments: ❑ Stk 466-SM1 ❑ Lodi 3583621 ❑ Manteca 823-7104 r Tracy 835-6386 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hammon Ave., P.O. Box 2008, Stk., CA 96201 INFO FH AMOUNT DUE AMOUNT REMRTED CK DASH pEL'ENED m DATE. PERMITNO. ) DI I{,a