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r APPLICATION FOR PERMIT r, •rX•• r,., SAN JOAQUIN LOCAL'HEALTH DISTRICT 1: . a U�'i:Jr 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YE.AR`FROM DATE'1SSUED n art 10 " '-V''` '=U? p7; ,, (Comple;eliri Triplicate)`,31.31C PRo.!E„OCI ;fir r"1�:'C: `1:•, i �' ; i 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 andj!he Rules and Regulations of the San Joaquin Local Health District. ' -'k -4 �' � ` - v 1. "e1;,;-;b WfvYv— 140 Job Address �V�''-�` City Lot Size l ��PLi.• PM Owner's Name u ' Address" -t J�1C S � ' -Phone• 7 ContractdtiLytQ _ n-1c'. Cd Address!. 7 6�..• t" License No TYPE a a Phone 64-5-/o IT OF WELL/PUMP: NEW WELL f-! WELL REPLACEMENT'0 DESTRUCTION ❑ PUMP INSTALLATION CSYSTEM_REPAIR_LJ_ �__..�� __OTHER_❑.�____� _} DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE l FOUNDATION AGRICULTURE WELL OTHER WELL_ PITS/SUMPS i— INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private D Gravel Pack } D Tracy Type of Casing 1. S Specifications D Public ' ❑ Other i ❑ Delta Depth of Grout Seal _ ----- ~- . Type of Grout F Irrigation ! ---Approx. Depth f_l Eastern Surface Seal Installed by Repair Work Done J Type of Pump H.P. - State Work Done -_ s Well Destruction D Well Diameter Sealing Material (top 501 I Depth Filler Material (Below 501 1 V TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION L DESTRUCTION ❑ (No septic system permitted if public sewer is r available within 200 feet.). Z Installation will serve: Residence Commercial,_ Other Number of living units: _J__ Number of t drop Character of soil to a depth of 3 feet: CX./��_� � ,' Y.-O, Water table depth SEPTIC TANK s W Type/Mfg LCL"`• Capacity_/o�<C3 No. Compartments h PKG. TREATMENT PLT. C f ( Method of Disposal �• , Distance,to nearest: Well �� Foundation Ll� Property Line LEACHING LINE It! No. &'Length oflines '•f Total length/size 'Q FILTER BED ^1 7 Distance to nearest: Well !'��Foundatio :J Property Line L /� SEEPAGE PITS Zr' Depth "Size` ' �� N.,'` �`� Number SUMPS *_ ❑ Distance to nearest: !Well _yFoundation �f,n <; Property Line S '� DISPOSAC'PONDS D l� __�� ! ~, �- hereby certify that.l have prepared this application-and that the work will.be,done in accordance with San Joaquin county ordinances, state laws, and rules and regulations.of,thre San Joaquin Locol,Health District. I '� '� F Home owner-or licensed 'agent's' certifies the following: "1 certify't'hat in the performance of-the ork for which this permit is issued, I shall not employ aHy persoh in such manner iirto-Deco6 subject to workman's compensation laws of Califomie.'�,ConfractOri hiring or sub-contracting signature certifies the following:•"I'certify.that in the performance of the work for which this permit is issue-d,-71 shall employ persons subject to workman's compensa- tion laws of California." ` " �_ _' f`� 1% t,�,,.�.� _:- . The applicant st call for II requiredlinspections:.Compete drawing on�iever`se�si'j� U ' Signed ` .' f.t Title; "T'--�` (' -t� Date:.. FOR DEPARTMENT USE ONLY-) i a Application Accepted by'^ Date Area , ✓ . Pit or Grout Inspection by~ ' ` _ _ .. Date__ Final Inspection by % Date Additional Comments: ^' E' - ' ' ✓ y1_ ❑ Stk 466-6781 -O Lodi 369-3821 1 Manteca 823-7104 ❑_ Tracy 835-6385 Applicant-f Return all copiis to: En�ironrnental Health Permit/Ssrvioea 1601601 E;Hazehon Ave., P.O. Box 2009,Stk.CA 95201 ;FEE AMOUNT DUE AMOUNT REMITTED CK a RECEIVED BY DATE PERMIT NO.- 'INFO CASH + EH 4-2a EH 13-24(REV.i%aei i -