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' y F ' APPLICATION FOR PERMIT { Ii SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA II Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i - 1Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to Construct and/or install the work herein deactihed.This aPpitication is made in compliance with San Joaquin County Ordinance No.549 lot sewage or No. 1861 fur well)pump and the Rubs and Regulations of the San Joaquin Local Health District. Job Address it Crit -- - Lot Site ! t Owner's Name L Address Phone !Y --------- i Contractor I { doe w �) J^ 7 rile NO Phone_ TYPE OF WELL/PUMP: NEW WLkL I WELL REPLACEMENT L] IDESTRUCTION L PUMP INSTALLATION 0 SYSTEM REPAIR LI OTHER 113 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD- PROP. LINE i 4 FOUNDATIO_N_T. AGRICULTURE WELL _ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS_ i I Industrial Ll Open l3ogom Cl Manteca Die. of Wnlr E.t.,rvanon--- � Dy of Well Casing 1 ; OomesticlPrivate L-1 Gravel Pack 1.1 Tracy Type of Cdsu,y _ Specifications 1'1 Public 11 Other V1 Della Depth of Grout Seal -__ _ Type of Gtoul --- __ I I Imt)dtson _..__ Approx. Depth I I Eastern Surldcu Sual h,atdilud by i Repair Work Done t 1 Type of Pump H.P. __ __ ,•_,_.__ __Y__ State Work Done - I, Well Destruction Cf We11 Diameler Depth — F,Ilur Material (Below 50'7 TYPE OF SEPTIC WORK: NEW INSTALLATION V? Flt a,r.Rt ADDITION I I Of.STRIICTION I I INo septic system permitted it public sewer is i available within 20D feet.) :{ Installation will serve: Res' once--� Commercial— Omer—_-, _ i1 Number of living units; _.!! Number of bedrooms Character of[tail to a depth of 3 tees: _ .¢msµ Water table depth SEPTIC TANK 1-1 TypelMf ' 4'� �' l 3 g -- - s-.-_- Capacity ,. . _ No. Compartments PKG. TREATMENT PLT.1_1 Method at Disposal Distance to neatest: Wall Fggndauuri _/. . _ Property Line LEACHING LINE l.t No. 8 Length of lines Total length/size - -. FILTER BED I.) Distance io nearest: Well��-�' r, h Property Erne 1 - +Foundat;nn _._.. pg y , L q i SEEPAGE PITS I I Dep11h! __. 41-1. . �rnber " SUMPS l I Distance to 1 irrearest: We11 pro ?{ r J perty Line DISE QSAL. PONDS E ! � - I huruhy curtly 01411 I have prepared this application and that Min wnik w,il be,lyric rn a,;cardance with San Joaquin county ordirunces,stale laws, aril a rules and rogutations of the San Joaquin Local Health Drslnct F1Umu owner or licensed agent's signature certifies the following: "I certdy that in assnperlorrttance ut the work lot which this permit is issued,I sttallno mrrploy any person in such manner as to become Wbktcl to workman's compensatrun laws at California."Contractors hiring or sub,contrac i curtrhas t1a faflowing; I certify that in th wformance of the work tar which This ornul is issued,I shall em la Irng s+gnat se H V P P Y Persons subject sa workman's Wmpensa ' cion laws cit California," j Thu afiPhcant nus,t cad lorjW requiree1%pections. Cain to drawing '� ... -%' �� - =;�,1,. .' _ -•_-- o ti,pne( X.-VI Title: _�b_ _.-..-_ Date: FOR DEPARTMENT USE ONLY 1 Atrl+l,,.nnOr:Acraptad bV _: -+�f✓<!fs --- _ _ Date�1 At. F,i ur Giaut Inspection by _ O.:I" -_ Final Inspection i %c,l� ,nal Curnmenfs; b �L -5 �r by Date Ir ik at6 678t C1 Lodi 369,3621 L_7 Manteca 823-7104 171 Tracy 8356385 �'I,r+Lc ant - Relurn all copies to-EEnvirunmentsl tiealih Pasmrt/Services 1601 E. Hazelton Avg., . , .,P.OBox 2MStk.. CA SWI n �• I: I+'If fI_Ati_1O_Q..N�T-O_U.kT A-M-O-LW- 7 raar] LMIT7Ed CA�I IELEIVEO 3Y DATE PERMIT'No.