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° t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.- HAZELTON AVE., STOCKTON, CA { Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E (Complete in Triplicate) s dlor install the work herein described. This application is Application is hereby made to the San Joaquin Local Health District for a permit to construct an made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules an�R Regulations of the San Joaquin Local Health District. 1 ZL.9 E 14 �T 4 _ City= N- Lot Size PM .lob Address �T�QLI.0 C1�fA2 r Address a. 1lTQCk�r� Phone �� Z. Owner's Name . pSZO1 Contractor 5� LO(�TCO&I Address z 6- T M E S`ir License No.�57- ZZ6$_Phone�tA '� —12 YS WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPE OF WELL/PUMP: NEW WELL ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER.<3 MON MRSA 6, We DISTANCf.Td NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �0 � PITS/SUMPS a FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Wel! Casing Z ACACS i� Industrial ❑ Open Bottom ❑ Manteca Dia. of Well•Excavation F1 Domestic/Private Gravel Pac IINfl}d Tracy Type of Casing V� Specifications Ll th of Grout Seal 740FT� Type of Grout��-_��-7 (Tl Public F1 Other Delta Dep G�Y<7tTYi' I I Irrigation - ",Approx. Depth I I Eastern Surface Seal Installed by t Repair Work Done [3Type of PumpH P State Work Done t Well Destruction ❑ Well Diameter; Sealing Material (top 501 Depth 1 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 :REPAIR/ADDITION l I DESTRUCTION I I (Nailable septic yst m rented if public sewer is Installation will serve: Residence�, Commercial Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet:I' Compartments SEPTIC TANK ❑ Type/Mfg; Capacity No. I PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS l I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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. - k 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 X)IV • employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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 must call for all required inspections. Complete drawing on reverse side, f Signed X Title: acra,lt�sl �r�V{�1 Ut-�`¢�— Date: IL19O FOR DEPARTMENT USE ONLY i Date 77 30 . 90 0 Area q Application Accepted by C !' Dates / �� Final Inspection by — Date 0 7 k Pit rout inspection by 1 Additional Comments: LJStk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 D Tracy 835 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.. CA 95201 i FEE K RECEIVED BY DATE PERMIT No. INFO AMOUNT DUE AMOUNT REMITTED CASH E +.EH 13-24 IREV.1/ 51 EH 14-28