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VI U1 1 OFFICE HOURS �" r r � 8:00 to 9:00 A.M. 3 , 3117 1 PLICATION FOR PERMIT aulN LOCAL HEALTH DISTRICT RAYMOND BORGES, R.S., R.D.I. AZEL T ON AVE., STOCKTON, CA Registered Sanitarian Telephone (209) 466-6781 1601 East Hazelton Ave. IBES 1 YEAR .FROM DATE ISSUED P:O. Box 2009 (Complete in Triplicate) Environmental Health Division Stockton. Calif. 95201 San Joaquin Local Health District Phone:(209)468-3445 District for a permit to construct and/or install the work herein described. This application is 549 for sewage or No. 862 for well/puinp and the Rules and Regulations of the San Joaquin LOC41 neann uismcr. r Job Address ity Lot Size Z�Z PM Owner's Name ,m 1 "� ' Address 9�0 r' ' fit w Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: WE W97REPLACEN1EhlT ❑ UCTION ❑ PUMP I SIAL N ❑ W_ YS-TEM REPAIR ❑ THER ❑ DISTANCE TO NE REST: SEPTIC AL SEWER LINE ` DI POSAL FLD. PA P. LINE , FOUND TION •� AGR1 WELL 0111 HER WELL PIT /SUMPS --D INTENDED US TYPE F WELL L REA C NSTRUCTION SPE IFICATIONS ❑ Industrial ❑ Open of © me ❑ anteca Di . of Well Excavatio Dia. of ell Casing f stic/Private a ack y T acy Ty e of Casing Specific tions y� M Public _ Other , !l D ha D h of Grout Seal Type of Grout — I I Irrigation _.Appy x. DepthI I E stern Su fad a ak installed y ' r X/ Repair Work Done Type of Pu p P. k D e_ M Well Destruction C) Well Diameter. #t laling Material atop 50 Iler Materia{ IBeIgw.50 — TYPE OF SEPTIC WORK: NEW INSTALLAT.I N REPAI.i/ADDITION I I ' DESTRUCT N I (No Sep c system permitted if public sewer is ` avai able within 200 feet.) a i Installation will serve: Residence C9mi nerciN Other Number of living units: Number of b drooms' Character of sail to a depth of 3 feet: ter table depth SEPTIC TANK Type/Mfg �Cpa it y�+� {�;� N - Compartments PKG. TREATMENT PLT. ❑ ?, - ` M thgd of Disposal Distance to n are t: Well ) Fouftd,tun— Z�� Prop rty iite I QU ,` LEACHING LINE .15 No. & Length'bf lines - -T t l 14h.gth IsizA FILTER BED ❑ Distance to rears t: Welltl 0 FFaur�d tion -.'_Pro erty Line OC) .I rid .F-F-'- SEEPAGE PITS I 1 Depth Z Size 4�i umber- SUMPS L7 Distance to neatest: Well Grr Foundation r� r/ Pro erty Line DISPOSAL PONDS 0 J I hereby certify that I have prepared this apptica ion and that the work will be'�dohe id aroofdanc�with an oaquin co my ordinances, state laws, and rules and regulations of the San Joaquin Local ealth District. r Home owner or licensed agent's signature ce ifi s the following: "I certify that in the perform nce of 1h wo for whic this permit is issued, I shall not employ any person in such manner as to bec el subject to workman's compensation laws of aliiornia." Co r tar's h ring or sub rcontraoting signature certifies the folio ing: "1 certify that in the pe rfnance of the work for which this permit is issu d, I shall play ersons ubject to workman's compensa- tion laws of Cali rnia." The applicant st call for all re uir9d irks tio1 .--Gemplet Signed X �? ` itle:.- t` 1_�;,,,n{r= - at ti ti R DEPARTMENT USE ONLY Date Area Application Accepted by Pit or Grout Inspection by Date Final Inspection by to Additional Comments: ❑ Stk 466-6781 ❑ Lodi' 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to-,Environmental Health Permit/Services,1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520 FEE OUNT DUE AMOUNT REMITTED 6PH RECEIVED BY DATE' PERMIT'NO. INFO w` ♦ EH 13.24(REV.t/N 5) / 0: ` j EH 14-2B f _ L