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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT p pM VETO `( 1601 E. HAZELTON AVE., STOCKTON, CA RRGE1 Telephone (209) 466-6781 „� /d l• ��? PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Jf (Complete in Triplicate) �MFN?AL HEA1T� V "ails application is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install tFbyl made a compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/Dump and the Rule p rations of the San Joaquin Local Health District. 11Ljl ( L{ p3=�' SF11 fJG— AJ� , city `'lc�ci�iol tsi:a PM Job Address \Lc,O SHI I " SIS SCLC CEF 105'O / S1 �e7CiST� N • F 1C -7-70c)2- Pho owner's Net.. �n�" �� N r] Addres -7-70-7-70c)2-S KVILHAUG License No. NS�3�I0 Phone Contractor 1676 11 ROAD Addles TYPE OFWELL/?UiAP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ `—' SEWER LINES 7Jt7 DISPOSAL FLD.�— PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL1�� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO�f S i t_Ly h `u Dia. of Well Casing 'T v ❑ Industrial ❑ pen Bottom ❑ Manteca Dia. of Well Excavation Type of Casin V L Specifications '^ ❑ Domestic/Private Gravel Pack ❑ Tracy YP 9 77 ❑ Delta Depth of Grout Seal .S Type of Grout 9) I I7 Public ❑ Other C.�M'T1�YI"� J(� - ��I Irrigati � —.Approx. Depth I 1 Eastern Surface Seal Installed by XVptv,t l � H.P. State Work Done_ Repan ork one Type of Pump Sealing Material (top 50'1 Well Destruction ❑ Well Diameter � g Depth '`l C9 I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION I I availableseptic wthin 200 feet.)in p if public sewer is Installation will serve: Residence— Commercial— Other 1 Number of living units: _ Number of bedrooms Water table depth Character of soil to a depth of 3 feet: No. Compartments ❑ Type/Mfg Capacity , SEPTIC TANK Method of Disposal (� PKG. TREATMENT PLT. ❑ Property Line Distance to nearest: Well Foundation Pe Y Total length/size LEACHING LINE ❑ No. & Length of lines pro Line FILTER BED C1 Distance to nearest: Well Foundation property Size Number I I Depth SEEPAGE PITS SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl I 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 rn 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 csub-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 t call for a Ir inspections. Comptete drawing on r On's e. 46 Title: . Date: Signed OR DEPARTMENT USE ONLY y ` D to ZJ23I&� Area �G Application Accepted Jb� � , -- ygy mw �. �vt. PA lJ Date Final Inspection by Date 3/ Pit or Grout Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7109 ❑Tracy G, P.O. Box 2009, Stk., CA 95201 Applicant - Return all copies to: Environmental Health Permit/Services(1+601 E. Hazelton Ave., P. 2 rFEE e+-' S —vwAsCK RECER/ED BY DATE PERMITNO. gMOUNT DUE OUNT REMITTED CASH '1O 5 �i5 i IC) d� ��d )�$� .�