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/ APPLICATION.FOR PERMIT c SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,,STOCKTON,-CA ` Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i. (Complete in Triplicafe). 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. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. - Job Address -77S/ F .'.N lJ y i - - �.'�� - ' . City Cl f_1' ',�1�'1r4 .} Lot Size - PM IC,� Owner's Name�-t 4/IVYUL.�,( e A Address+ C, I70K pr 7"` •t J '�(A�f/l'•" Phone - � .Contract Address PO BTA b" License (0O_ I r� 1` 1 TYPE OF WELL/PUMP: License No. 2 Phone AA VI NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 1 SYSTEM REPAIR El OTHER O (/\ DIS ANCE to NEAREST: SEPTIC TANK SEWER LINES i DISPOSAL FLD. PROP, LINE 1 �3 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDES'ISE TYPE-OF_WJELL_�P-ROBLEMAREA.-.CONST.RUCTION-SP-ECIFICAT40NS-- (� -❑ Industrial 71 Open Bottom III Manteca Dia. of Well Excavation4 1 Q Dia. of Well Casing t.Oomestic%.Private �,,❑ Gravel Pack ❑Tracy Type of Casing ❑Public {J Specifrcetions ❑`Other ❑ Delta I Depth of Grout Seal ❑ Irrigation j Type of Grout 0 _A,prox. Depth ❑ Eaire'm ,: „ Surface Seal Installed by Repair WorkDo'fie"'p—fyp—e37"Pump t • j H.Pr, Stale-Wo•' rk Done ^ 1. Well Destruction ra—Well-Diameter r— Sealing Material (top"50'1 �. Depth FillerMaterialMelo 50'1 TYPE OF SEPTIC�YVORK:, NEW INSTALLATION ❑ REPAIR ADDITION DESTRUCTION ❑ (No septic system permitted H public sewer is ' available withJjp 200 feet.) Installation will serve:.yResidehce Commercial Other _,(,(y `3_C_, [�Q/k.0 y e Number of livin units f q r L/ 4 �J_ � lip- �"^ 9 }-�� Number olhbedrm s; Character of soikto a depth of 3 feet: a ` SEPTIC TANK �p T' /Mf ) 1 V 1 ( I?, Water table depth 0 9 Capacity o. Compartments PKFi. TREATMENT'PL-T:-O^I 'E-=---.-.---...�;.—L r' Methpd�of Disposal .-tistance to nearest: Wall Foundation Property Line I- LEACHINGIINE ❑ No. & Length`of lines Total length/size FILTER BED 1-4y-1 r, .. ❑ Dis it�e fosnearest: Well - Foundation -Property Line -� SEEPAGE PITS ❑ Depth �n Size % Number- . SUMPS -.I [$ Distance to-nearest:—Well foundation-1-(�.�_-:.property+:ine-;jam - DISPOSAL PONDS �.---0- . i I hereby certify that Iihave prepared this application and that the work will be done in accordance with San Joaquin.county ordinances, state laws,and rules and regulation pf the San Joaquin Local Health district.' ' Home owner or licensed agent's signature.00r ifies the fallowing ce r^ � employ an I ^9: •, rdfy thai in the performance•of the work for which this permit is issued, I shall not Y Person inIsuch mannereae,(o.bepgttlaj)�jbjeci to workman' comperisation lawf'dt Calif6rn'ra' '.Contractor's hiring or sub-contracting signeture tiocertifies ro lewst the folio omi8:'I ce�that in the performance df the work OFs p" ns this permitissued,I shall employ pns subiect to workman's compensa- The applicant must c(tll for I req "red inspections. i Comn r �p � plete drawing oreverse side. Signed ___ _ '�""-`-'� w--t_J Title: FOR DEPARTMI=NT/USE ONLY Application Accepted by -` f rt y+� _ _Date prey V - r Pit or Grout Inspection by `r T Date Z Final Inspection b _- V Date Additional Comments: " _ .. ❑ Stk 488-8781 Lodi 369-3621 ❑ Mantes 823-7104 ❑ Tracy 836-63&5 Applicant- Return all copies to: Environmental Health Permit/Services 1681 E. Hazelton Ave., P.O. Box 2009, Stk., CA SIMM FEEgMOUN7 DUE AMOUNTREMRTEDCK INFO CASH RECEIVED BY /DATES PERM FO 1N ` U/'/ � ' + EH/ in". 7 EM/4ZE (/