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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 00LT 2 tr --� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 10 (Complete in Triplicate) '• Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work(here n described This'a'pplication is made in compliance with San Joaquin County Ordinance No.509 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin VV Local Health District. E_ Job Address Ale4tL &l/e'ro City Lot Size (/ q PM,/ Owner's Nam �//e'y-{7��CJ � Address �2C /1, Phone/()5 l 716 Contractor P ' "" Y LI/'o� Address 10a PO ANO, `A License No. 263- OSS Phone�i32�-8 �G TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C3M SYSTEM REPAIR ❑ OTHER>d / 0771 f0_U'(7// We DISTANCE TO NEAREST: SEPTIC TANK Nq SEWER LINES 2..5C / DISPOSAL FLO. / � PROP. LINE >SL 1 FOUNDATION >•.SC' AGRICULTURE WELL N OTHER WELL�25 / PITS/SUMPS NA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation O-//IG Dia. of Well Casing ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing PVC Specifications F1 Public ❑ Other fl Delta Depth of Grout Seal c Type of GroutCL�''C' L_;u;'' I I Irrigation /ZC:qpprox. Depth 11 Eastern Surface Seal Installed by /' hDrling _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50.1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial _ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ 1 hereby certify that I 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 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 for which this permit is issued,I shall employ Persons subject to workman's compensa- tion laws of California." The applicant-tJnust call forallrequired inspections. Complete drawing m reverse side. Signed X o' CW�' r` • �C Rc. Tine: Ta/�CLv>'L,c S li2�J�'Ps[',nflff/Da"te 1012 7-Zu FOR ,t.D1€PnARTMENT USE ONLY �( Application Accepted by t �"'w�` Date u / Area �7 , Pit or Grout Inspection by_, QQ DateFinal 1 pectionby 1 U> Date w Additional Comments: �'}-- rG 1� /4] 1 VFw /,63 I` 11 Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 83L5-63885 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201ElI IN A(Mr,O(U�NT DUE AMOUNTyREEMITTED CASH RECEIVED BY DATE PERMIT'NO. 11 �J r EN 24(REV.t i n si