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_r ✓ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1611 F HAZFLTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Has"District for a permit to construct and/or install the work herein described. This application is made in comphance with San Joaquin County Ordinance No.549 for sewage or No. 1882 for well/Dump and rhe Rules and Regulations of the San Joaquin Local Health District. Job Address -3-7Q 1 15 v ` rP f—+t -- City LO()/' Lot Size 7 Y PM Owner's Name D4 rw ms Address ��/ ___ y� Phone Contractor to '�- Q L4 r Address M(0 dish (u9 License Nop , 5:S'XP1- Phone 4;ksTr"�Ir TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION J SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS G Industrial ❑ Open Bottom ❑ Manteca Dia. of Wea Excavation -. Dia. of Well Casing w ' ❑ Dornestio/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 11/ Yt Public Ct Other Cl Delta Depth of Grout Seal Type of Grout 1 1 Irrigation _Approx. Depth I I Eastern Surface Soul Installed by - �j Repair Work Done ❑ Type of Pump H.P. - State Work Done - pjl`�\1 Was Destruction 0 Well Diameter _ Sealing Material (top 501 p Depth Filler Material (Below 501 +\ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is 11 available within 20D feet.) Installation will serve: Residence�Cornrnerciel_ Other Number of living units: —I— Ntanbeir of beskooms�-. Character of soil to a d�epthh f 3 feet: JL{71 Water table depth____ -L SEPTIC TANK fH Type/Mlg p.j-L r.dY1Cs/'6Pe. Capacity --4aLML0— No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposel {� Distance to nearest: well 100+- Foundation —LS:L_ Property Line 11 A T LEACHING UNE V-No. 8 Length of lines Nn Total knlgth/size l�6 _ _--_— MFILTER BED ❑ Distance to nearest: Well 1QQ+ Foundation _ Property Line pO y r SEEPAGE PITS V(" Depth �'S Size r Number SUMPS U Distance to nearest: Well� _ Foundation �— Property L'es DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances. state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature cartifies the following: ..I cartify that in the performance of the work fp Mitch this pemuit is issued, I shag not employ any person in such manner as to become subject to workman's Compensation laws of California.-Contractor's hiring a sub-contracting signature certifies the following: "I certify that in the Partorrnance of the work for which this psrnvt is issued,I shwa employ persons subject to wotl man's compensa- tion laws of California." The applicant must call for ellz1requirsd inspections. Complete drawing on reverse side. Signed K 1. l_ p�.s./ Tulle: - -- Date: V FOR DEPARTMENT USE ONLY Application Accepted by T� Date 114-- =ref- Area _� Grout Inspection by-reDate )LJrinel Inspection by Date .., F' Adck#orwl Comment: —_ ❑ Stk 486-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy 8358385 \.+ Applicant Retum all copies to: Environmental Health Permh/Services 1601 E. Hazelton Ave., P.O. Bax 20(19, Silk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMIT'NO. NFO . EH 14NU `-