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.. .. .. -.. .. -. ,,,g.p.�.�;�:: .-`�h?Ii::e'NXrJac'vestsx,=R�'�aoc�ita['�t•v.n.a�t>,- PF'LICATION FOR PERiJ11T SA JOAQUIN LOCAL HEALTH DISTRICT t 1,15— E. HAZELTON AVE.. STOCK TON, CA Tefrphone 12:.91 466-6781 :•5 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) App'tcatinr is Le1_by made to the San Joaquin Loccl Health District for a r,mmir to crnstruct and/or install the work herein described.This spin Joaq is - mada n ce„lplian_b with San Joaquin County Ordinance N-,.549 for sewap^,). No. 1862 for well/pump and the Rules and Regu;ntions of the San Joaquin Local Health District. r 4e— G PM _ Lot Si:c - Job Address Phone �3v11� c:_ —P�_ Addr,:ss Owners Name r A �c�r Phone � �.,Z, /"�iL� _Address License or.tractor NEW WELL ❑ WELL REPLACEMENT [J DESTRUCTION C TYPE OF WELL/PUMP: MP: PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ _ C!SPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES PITS/SUMPS FOUNDATION AGRICULTURE WELL -- OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ Dia.of Well Casing ❑ Industrial 0 Open Bottom ❑ Manteca Dia.of Wel Excavation_ Type of Casing _ Specifications ❑ Domestic/Private ❑ Gravel Pack •U Tracy Cl c ubliType of Grout FI 1 P _ Other n Delta Depth of Grout Seal _ y: epth I I Eastern Surface Seal Installea by 1 I ubli ion —Aoprox. D Repair Work Done U Type of Pump H.P. State Work Done— Well Destruction ❑ Well Diameter Sealing Material (top`,u'). r Depth Filler Material(Below 501 yJ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADUITION DESTRUCTION I I (Noavasepiic syst 200 feet.) d public sewer s 93 Installation will serve: ResidenceCommercial— Other 9' ' pNumber of bedrooms y3-- Number of living units: _IQ Water table depth `t Ch:ratter of soil to a depth of 3 feet: � ��3No. Compartments T� Capacity_- SEPTIC TANK ❑ Type/Mfg. C clNi- Method of Disposal PKG.TREATMENT PLT.C } ! Xr�p-r _ r`�— T l 1 - - Distarte to nearest: Well 51-- Foundation_/� Property Lne Total length/size-14a No.& Lenth ar lines LEACHING LINE g /�"�fT-Property Line FILTER BED ❑ Distance to nea est: Well 7��_Fou:tdation I I Depth Size Number ' h SEEPAGE PITS Property Line LI Distance to nearest: Well Foundation_ SUMPS I DIS,")SAL PONDS ❑ with San Joaquin c�unry or ?: I hereby certify that I have prepared this application and that the work will be done in accordance dinances,state laws,and 3 rules arvf regulations of the San Joaquin Local Health D3trict. 1' Home owner or I:censed agent's signature cart"ides the fr flowing: "certify that in the performance of the work for which this permit is issued,I shall not ! employ any Person in such mannerbrto tecome subject to workman's comp ensation.law>>t California.".hllemploy pensContractor's hiring c sub contracting signature . certiftes the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for I required inspeyli ns. Complete drawing on reverse side. �� Date: Si Fled X '+..ALS Title: _. — POR DEPARTMENT USE ONLY ZjG ,�'y DArea ate Application Accepted by ZQ' PC Ft.,al Inspection by v Data Pit or Grout Inspection by Date :•.dditional Comments: i C Stk 466-6781 ❑ Lodi 369 3621 C1 Manteca 823.7104 L1 Tracy 835-6385 ll copies to: Enwonmental Health Permit/Services 1601 E. Hazelton Ave., P.O. 3ox 2009, Stk., CA 95201 Applicant-Return a FEE RECEIVED BY .. AMOUr1T DUE - -� AMOUNT REMITTED CASK�-" INFO •[Y 1}21 r. �O n�i 1v EN 1426 -