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APPLICATION FOR PERMIT 4 SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZELTON AVE., STOCKTON, CA ` Telephone (209) 466-6781 ')PERMIT EXPIRES 1 YEAR FROM DATE ISSUED T (Complete in Triplicate) n described.This cation LS Application is hereby made the ui nCounty Ord nalnce No.549 for sewage or tNo. 1862 for well//pump and the Rules and Health District-for a permt to construct and/or install the work IR Regulations of the Sant Joaquin made in compliance with Sann Jo q Local Health District. f3 / 2-0 G t A V A Y✓� Lot Size PM City Jab Address 79-9z �� �/'` Address - �- � �6 Phone Owner's Name / 41 13g '�4 9� �, License Na. +S Phone 33 Contractor 7 Address_" DESTRUCTION ❑ TYPE OF WELUPUM NEW WELL WELL REPLAGEMEN7 El SYSTEM REPAIR ❑ OTHER ❑ PUMP INSTALLATION ❑ ,�— DISPOSAL FLD.r +� PROP. LINE 1 SQ ��^^�� SEWER LINES DISTANCE TO NEAREST: SEPTIC TANK . rise— .„ OTHER WELL r PITS/SUMPS ..� J FOUNDATION _ — AGRICULTURE WELL A ELL PROBLEM— EM AREA CONSTRUCTION SPECIFICATIONS INTENDER USE TYPE OF WDia. of ❑ Industrial ❑ Open Bottom ❑Manteca' Dia. of Well Excavation f WeI�� ❑ Tracy Type of Casing ! �'�l Specifications omestic/Private ravel Pack Type of Graut� --- ❑ Other r Delta. Depth of Grout Seal V I'1 Public Surface Seal Installed by I 1 Irrigation --Approx. Depth l I Eastern Repair Work Done L1 Type of Pump H P State Work Done_ G Sealing Material (top 50'1 Well Destruction EY' Welt Diameter Filler Material (Below 501 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I ! REPAIRlADDITION i,l DESTRUCTION I I availabletc system wthin 200 feet.) permitted if public sewer is Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Water table depot Character of soil to a depth of 3 feet: No. Compartments Capacity SEPTIC TANK ❑ Type/Mfg ^'' Method of Disposal f PKC. TREATMENT PLT" ❑ *property.Line Distance to rest: Well Foundation fs t Tota! length/size LEACHING LINE ❑ No. & Length of lines property Line FILTER BED ❑ Distance to nearest: Weil oundation ` f l Depth Size Number SEEPAGE PITS • ---Property Line ` ❑ Distance t earest: Well Foundation :SUMPS DISPOSAL PONDS ❑ - - I 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 the San Joaquin Local Health District" Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not s of California." employ any nsation cartifi s the following.person in Ic erifynthat n the performaner ai to become cject e ofothe wok for which ethis permit is issued,I shall employ personslsubject to workman's ring or tcompensa- _. tion-laws of-Califomia. *i- -,r01 , T The applicant mu for all required spections. omplete drawing on reverse side. / - M1 Date: Title: Signed.X 'FOId DEPARTMENT USE ONLY #. Date� � Area Application Accepted by Date Final Inspection Pit or Grout Inspection by by Date ►_ 4� - �r - Additional Comments- 0 C3 Lodi Manteca 823-7104 ❑ Tracy 835-63B5. Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK RECEIVED BY DATE PERMIT'NO. I FEE AMOUNT DUE AMOUNT REMITTED CASH INFO f II ( '�7�Q f7) I *.EH 53.24(REV,t/K 51 ( 1 EN 14.28 i