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J i APPLICATION-FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT sr I 1601 E. HAZELTON AVE., STOCKTON, CA - TelepFione (209) 466-6781 _. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ..rr (Complete in;Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or kistall 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. 3 .� n ,, s 1t; ::.• Job Address 3` q q I• C Lot Size�41 €1 W moo, �4 Owner's Name _ Address • / hone I Tt Contract / r d Address _License No t'hone l TYPE OF WELL/PUMP: NEW WELL ,7 WELL REPLACEMENT Cl DESTRUCTION ❑ PUMP INSTALLATION L SYSTEM REPAIR fJ OTHER L7 DISTANCE TO NEAREST: SEPTIC TANK __ - SEWER LINES _-"DISPOSAL FLD._ PROP.71LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ` w INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � i OIndustrial J Open Bottom 1 Manteca Dia. of Well Excavation_ _ Dia. of Well Casing �Q C Domestic/Private ❑ Gravel Pack L Tracy Type of Casi gr Specifications y 1 ❑ Public 17- Other O Delta Depth of Grout Seal Type of Grout A F-1 Irrigation _ Approx. Depth I Eastern Surface Seal I stalled by ERepair Work Done C Type of Pump _ _ H.P. " _ I State Work Done l Well Destruction LJ Well Diameter ' r Sealing Material flop 501I— Dep th �r Filler Material(Bel ') \ TYPE OF SEPTIC WORK: NEW INSTALLATIONEPAIR/ DITION M DESTRUCTION D (No septic system permitted if public'•sewer is �} Y.. . a ilable within 200 f t.) �Y Installation will serve: Residence_ Commercial.-X Ocher - Number of Irving units: _---6L Number of bedrooms_ •B Character of soil to a depth of 3 feet: _._ e �f� —Water table depth— I SEPTIC TANK U Type/Mfg I N r Capacity No. Compartments I I ` Method of Disposal I I PKG. TREATMENT PLT. O ", L Distance to nearest: Well I Foundation_ Property Line_.. LEACHING LINE No. 8 Length of lines 1 1 l 0 ---- Total length/size!)AQ 1- FILTER BED F1 ,.Distance to nearest: Vt7gB" �r� Foundation__ Property Line SEEPAGE PITS Depth ZJn _Size ;� Number SUMPS ❑ ;Distance-to nearest: Well `Foundation -Property-Line-I and DISPOSAL PONDS 1 i `F It 1 \ I hereby certify that I have prepared this application and that the work will be done in accordance with San Jtoaquinicounty ordinances, state laws, rules and regulations of the San Joaquin Local Health District. \ 4•t+3}`�1 i i Home owner or licensed agent's signature certifies the following: "I certify thin in the performance of the work'for which this permit is issued, i shall not employ any person in such manner as to become subject to workman's compensation laws of Cal fornia."Contractor's hiring c so workman' c signature certifies the following:"I certify that in the performance of the work for which this permit is-issued,I shall erndk�y peMors subject to workman's Compensa tion laws of California." r '' The applicant mu call for all requir d inspections. Complete drawing on reverse side. �. t Signed X_ - ��Q r Title:"'i% Date: 7 FOR DEPARTMENT USE ONLY �� - 4 Application Accepted by — -7 Arae Date U� Pit or Grout Inspection by - D.I. - Final Inspection by .; - Date :Ef � Additional Comments: O Stk 466.8781—0-Lodi-369-3621 —4L- 'Manteca-823-71104—LJ Tfacy• 835-6385 AppFcant-Return all copies'Ito: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I F£E AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO - INFO ��1Z�l-slp �sto-�itq ! • EH 13$4(REV. EH 14.7!! .. ��