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i� APPLICfITION FOS'. FtRMIT Ih � !! .� SAN JOAQUIN LOCAL HEALTH DISTRICT �` 1601 E. HAZEL T ON AVE., STOCKTON, C4 Telephone (209) 456-6781 "; 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 end/or install the work herein described.This app4cslon is mads in compliance with San Joaquin County Ordinance No.549 for sewage or No.1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health Distrirt. i. Job Address r A) Cit /!�[— Lot Size Owner's Na^�-n" Addretr. �ot)(Y�/✓, — Phone-l�1�=3J ` Conlr.:,lt� S�r]_L.S2�Address �?C%.!l??(7/,/ License No.��>�a .��Phorw TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL, OTHER WELL—+. PITS/SUMPS INTENDED U5E_ TYPE OF WELL PROBLT%1 AREA CONSTFUCTION SPECIFICATIONS r 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Oilt.of We4l Casing ..—' ❑ Domestic/Private ❑ Gravel, Pack ❑ Tracy Type of Casing_ Specificalionr f'1 Public I-I Other C� Delta Depth of Grout Seal Type OI Grout _ I I Irrigation __._Approx. Depth I I Eastern Surface Seal Installed by — ) Repair Work Done U Type of Pump H.P, _ State Work Dorn.. Well Destruction ❑ Well Diameter Sealing Material (top 501 _ N Depth Ilvler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION EPAIR/ DDITION I DESTRUCTION 111No septic system permitted if public sower s i available within 200 feetJ f. Installation vnll serve: Residence Commercial Other / f Number of living units: Number of rooms \ Character of soil to a depth of 3 feet: tM Water table depih SEPTIC TANK O Type;Mfg Capacity_ No. Compa.lmer PKG. TREATMENT FLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE P---No. 6 Length of lines f �i� Total length/size r / i FILTER BF.D I i Distance to nearest: Well_ �_ Foundation 4f�) Property Line r SEEPAGE PITS I I Depth Size___ flumber SUMPS L I Distance to nearest: Wei: F(.nidation _ Property Line DISPOSAL PONDS ❑ 1 I hereby certify that I have prepared this application and that the work will be done in^-.cordance with San Joaquir county ordinances,slate laws,and rubs and regulations of the San Joaquin Local Health District. Home owner v licensed agent's signature cert;'es the following:"I certify that in the performance of the work for which this permit Is issued,I shah not employ any person in such manner as to become subject to workmen's compensation laws of California."Cnntraetor's hiArq or sub-coxtVactinq sipnafure certifies the following:"I certify that in the performance of the work for which this permit is issued,I shalt employ persons subject to workman's compensa- tion lows of lornia." The applic�nE t call for Ir�aulr?di inspections. Complete d•awing on reveroe fie r SignedX / Title: Date: �I FOR DEPAnTMENT USE ONLY Application Accepted by rim Datta Ata+' -- Pit or Grout inspection by Date— _ Final Inspection 7y _ Date{"tQ Additions(Comments: ❑ Sit: 466-0781 L) Lodi 3693621 ❑ Mameca 8Z•-7104 ❑ Tracy 015-6385 Applicant• Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �1 FEE AMOUNT DUE AMOUNT REMITTED CA-.M RECEIVE)BY DATE PERMITNO. JH 24 IREV,I EH U 1a v