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¢/ F ' ,re`v.',:.� w..r-. �' Yyy•�ry'�' ..r 'Cf. .r APPLICATION FOR PERMIT "w At SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 436-6781 PERMIT EXPIRES 1 YEAR VAOM DATE ISSUED (Complete in Triplicate) Application?z heie5y made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This 8PPno1360n is nce No.549 for sewage or No. 1862 for well,pump and the Rules and Regulations of the San Joaquin r,iode in compliance with San Joaquin Cou.ity OrdinaLy: Jy Local Health District. �,/ QQ J ,,, /9G PM .lob Address _ 7/ham Y� 1\� Y h City/njo >� Lot Size ! ��,�y /t11 V �1T Phone 4 Owner's Named -�: r Address !� lygiTd.� License No. S�: _Fhone Contrar.tnr A, w Aduress_ a _ DESTRUCTION ❑ urL} TYPE_OF WELL/PUMP: NEW WELL 13WALL REPLACEMENT ❑ SYSTEM REPAIR ❑ OTHER ❑ ti PUMP INSTALLATION ❑ an; v SEWER LINES. DISPOSAL FLD._— PF OP LINE �st OISTAIVCE TO NEAREST: SEPTIC TANK PITS SU110 FOUNDATION AGRICULTURE;WELL OTHER WELL � INTENDED USF TYPE OF WFLLL PROBLEM AREA =,CONSTRUCTION SPECIFICATIONS _ ?"` _ _ Dia:of Well Gelkg3 b , ❑ Industrial,, ❑ Open Bottom ❑ Manteca C:a'.of Well Excavation Spettfie9tionsvJ - � � ^ Q• Ll Dortteetic/Private ❑ Gravel Pack ❑Tracy th of:y�e of Casing Type of Grout 4 >s _ f 1 Publk= F n Other M Delta DepGout Seal s Intgelkxt 4 �: _Approx. Depth I I Eastern Sviace Se:J installed by_ n ' Repair'sNork Done, ❑ Type of Pump H.P. Starr Work Dons Serlin Material(top 50'1 Wa:l Dostruction ❑ Well Diameter g Depth Filler Material(Below 501 x TYPE OF StPTIC WORK: NEW INSTALLATION I I REI, DESTRUCTION 1.1-alvailabeci ttwdhgne200 feet J. it public sewer is ¢; ?tj ,n<allation wai serve Residence A- Commercial_ Other 37tlJ Number of bedroocts Number of Irving units. Water table depth' Character of soil to a depth of 3 feet: Y . i7 Type/Mfg. Capacity/�SL3t-- No. Comparthients } EPTIC YANK �... Method of Disposa� ig Y/.G. 7REATMENT PLT:❑ Foundation fd Proper.y Line Distance to neareit Well �J�1 7D Y /— �� Total length/size LEACHING LINE . No. &Length of linos n T Foundation Propsrty Luse FILTER BED ❑ Distance to nearest: Well -q w' IDepSize d. ' Num G SEEPAGE PITS t — �� .fail r Property Line� 1- Distanc neaff'.SI. Well.� _ Foundation_ i, SUMPS DISPOSAL PONDS ❑ k I heroby certify that I have preparwf this application and that the work will be done in accordance with San Joaquin County ordinances, state Laws, and ruies and regulations of the San Joaquin Local Health District. - 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,1 shelf no employ any person in such mariner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signstufe� _ or which this permit is issued,'I shall employ persons subject to workman's Cortpensill <:ariifies the following:"'I csrify that in the performance of the work f ;ion lows of California." `} '-ne applicant must call r fired inspe-tions. Complete drawing on reverse side. Signed X Title: Date FOR DEPARTMENT USE ONLY y�f� � Date Application Accepted by "``��' Da Final Inspection by Pit or Grout Inspection by) s A itiontil Comments:tk •466-6781 ❑ Lodi 369-3621 ❑ M8.1tecs 823-7104 ❑ Tracy 835-6385 Applicant'- Re'urn all copier to: Environmental Health Permit/Services 1601 E. Hazelton A.ve., P.O. Box 2009, Stk., CA 95201 1, CKRECEIVED BY DATE - -PERMITINO.- -- --- - rFEE AMOUNT D('E AMOUNT REMITTED CASH w I INFO '_'_ '17e IREV.,r�71�