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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH .DtSTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. / 07 4/ 70-7 /pew JOD Ncaress 7 ---- ne Ar215(::::74r57 Address --C, 19- . / "." .... Pho Owner's Name ' J/4 ci7 502- r--(1"7-57 g. --i 7 Contractor tr tress /.‘2' 16'77 /r/i7 License No. • 7 Phone TYPE OF WELL/PU P: , _ NEW WELL C WELL REPLACEMENT 0 DESTRUCTION 0 PUMP INSTALLATION Li SYSTEM REPAIFiC7' OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGFilfULTURE WELL OTHER WELL . PITS/SUMPS ____ __ _____ , ..... _a__ INTENDED USE • TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFJCATIONS " 0 Industrial 0 Open Bottom fffirlanteca Dia. of Well Excavation Dia. of Well Casing 0 Domestic /Private • CI Gravel Pack El Tracy Type of -Casing • -- .- =--. - Specifications ....-,' 11 Public [7 Other El Delta Depth of Grout -Sa-------; 'Type of Grout I I Irrigation Depth I I Eastern Surface Seal Installed by __Approx. i Repair Work Done 0 Type of Pump H.P. i'St'i.4 Work Done i .. .., .. Well Destruction 0 Well Diameter Sealing Material (top 50') ..-- Depth Filler Material (Below.50•1 TYPE OF SEPTIC WORK: NEW INSTALLATION I :I • REPAIR/ADDITION X -DESTRUCTION -1'1 (No septic system permitted if public sewer is -../...-- , * ' available within 200 feet.) Installation will serve: Residence Commercial Other ' - i- • . . 7 Number of living units- Number of bedrooms 3 r ‘4 • Character of soil to a depth of 3 feet: . L,i9a Water table depth SEPTIC TANK Li Type/Mfg Agefla rgz-/. ' Capacity /ZIP 61 N. Compartments 2-- PKG. TREATMENT PLT. CI ' i Method of Disposal , f.....1 Distance to nearest: Well •LP - Foundation /2 Property Line - ...t. _ LEACHING LINE 0 No. & Length of lines ,_..1' , , . Total ler_igth-isize f‘i — 02 7.r' , ,. .„ .,.._ FILTER BED CI Distance to nearest: Well 575.7 '.' FOuritlItion cila- •"• Property Line & ' SEEPAGE PITS I I Depth :..., - t Number ______ __Size _ SUMPS 0 Distance to nearest: Well ' .- Foundation Property Line DISPOSAL PONDS a e."" I hereby certify that I have prepared this application and thatithe work will be done in adcordanCe with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the woli'le 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 California," Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work forwhich this permit is issued, I shall ()moldy persons subject to workman's cornpensa- . tion laws of California." The applicant must call for all required inspections, Complete drawing on reve side. Signed X A. 1,wer LI ? ARTM NT U E ONLY, ;4" Application Accepted by .. ' .,-;,:'•;. Dace Pit or Grout inspection fay' • Date Final Inspection by 1/1" Additional Comments- . 0 Stk 465-6781 Cl Lodi 369-3621 0 Manteca 823-7104 , 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Heatth Permit/Services 1601 E. Hateiton Ave., P.O. Box 2009, Stk., CA 95201 I ii., ' L /44,1, PM 4z42, Date /1/r? Area -4'3 - r 514 13-24 iREV, 1/ 4C EH 14-28 FEE INFO AMOUNT DUE AMOUNT REMITTED - CK 1 CASH RECEIVED BY DATE PERMIT NO. C Lay,..---- Ivi 7 Tr? '..2"--Liobi —7(c),(The--,