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+rY r I u y 4 �{ , ! p�ly Ir }�1j.-t - x,: „"�k�,!'?;r, a•w...tw.,..a., .:iyt '. `ItE�w..,.rm-awr+.ti. E rwK^ w'"'A"ta� . . M APPLICATION FOR PERMIT of dy SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA �� r 1 pct'" Telephone (209) 436.6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) rJ Application is heresy made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.TMs appilcation Is made in compliance with San Joaquin Cou.ity Ordinance No.549 for sewage or No. 1862 for well;pump and the Rules and Ragulationc of the Sim Joaquin r ,F, Local Health District. wG 'I i Lot Size .lob Address ��” �+� Y CityL—_ i Owner's Name �=i Address Phone p� V ---- Contrar•tnr--AJ—, cJ Ad ress_ - 1 License No.;P/_S_:a-F h o n e T T. TYPE CIF WELL/PUMP: NEW WELL ❑ WcLL R PLACEMENT ❑ DESTRUCTION ❑ kj ,',1= PUMP INSTALLAT10:4 171SYSTEM REPAIR ❑ OTHER ❑ '. DISTA14CE TO NEAREST: SEPTIC TANK __— SEN/ER LINES DISPOSAL FLD.`_ PrOP• LINE FOUNDATION AGRICULTUREIVti"LL OTHER WELL PITS/SUMPS INTfDED USF TYPE OF W�PLL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a -J----- - Dia.of Well Casing 1 ❑ Industnal� h:; O Open Bottom Manteca Cls', of Weli Ettcavation_ Cl Dornestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications ` . f'1 Public J% n Other n Delta Depth of Gout Seal Type of Grout I I Irfigatlun _.Approx. Oepth 1 1 Eastern St,-face Senl Installed by_. Fepair'Jvork Done ❑ Type of Pump H.P. State Work Dons_ `Ka'I Destruction ❑ Well Diameter Sealing Material(top 501 _ Depth Filler Material(Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I INo septic system permitted d public sewer is aC available within 200 feet.) [ n-%:alletion wiii serve: R'. !' / ' Residence � Comrr,ercial_ Other ?� Number of living units: ) Number of bedrooms i Character of soil to a depth of 3 feet: WRter table-depth_ h :,EPTIC TANK I' (7 Type/Mf§ Sr Capacity Compartments t ,rT—. t iethod of Dispose PKG.TREATMENT PLi:U .�-+ i >_. /' � _ /b y?n F Distance to nearest: Well� � Foundation J _ Propery Line LEACIIING LINE No. 6 Length of lines l�� y Total length/size FILTER BED ❑ Distance to nearest: Well Foundation 2 Property Line nn t7 Y, SEEPAGE PITS I I Depth —Size�P d NumJ&�' F � Property Line /^6 ' SUMPS Distance o nearest: Well.�- t—_ Foundation DISPOSAL PONDS ❑ "}' I hereby certify that I have preparrA this application and that the work will be done in accordance with San Joaquin county ordinances,state laws, and.,"ry„ µ` rules and regulations of the San Joaquin Local Health Di3trict. Homs 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 employ any persnn in such mar,ner as to become subject to workman's compensation laws of California."Cnniractot s hiring or sub contracting sig eJ. carifies 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 compensl sign lows of California." " Tree applicant must call 1orall r firedof inspections. Complete drawing on reverse side. Signed X CA !�C, v _ Title: L2-G�"cP1{ Date: / �✓�� FOR DEPARTMENT USE ONLY Date_ �_ Area Application Accepted by / �_'',,,Q" / 'g Da ��J.�rlFinsl Inspection by Pit or Grout Irspection by _ ;. Additional Comments: — I] Slit 166-6781 O Lodi 369-3621 ❑ Manteca 8237104 [1 Tracy 835-8385 Appliceni - Re•urn all copies to: Environmental Health Permit/Services 1601 E. Hazelton A.ve., P.O. Bo 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REWTTEO GASH RECEIVED BY DATE - PERMITINO. -- -- - INFO 66) .:0