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APPLICATION FOR PERMIT `` SAN JOAQUIN LOCAL, HEALTH DISTRICT i6ol E. HAZEL T ON AVE., STOCKTON, CA Telephone"12491 466-6781 i i PERMIT EXPIRES 1"YEAR FROM DATE ISSUED (Complete in Triplicate) Aaolicarion is hereov made to the San Joaquin Local Health District for a permit to construct andlor install the work herein descnbed. 'this abalication is mace in comotiance with San Joaquin County Ordinance No.749 for sewage or No. 1862 far'welt/puma and the Rules anti Regulations at the San Joaquin Local Health IDisthct. Jao Adaress 37as T��GL-/ 1��Jc� City Lac Sire PM . s Owns d Name sh e i d r I C0 Address 47 9 a 1�d)oto P,cl r� -d?l; Phone 040 -10 Contractor 1 , I254- M59z - n,4 Address a3 Lke:sse no. SSS(-717mom - X- TYPE OF WELL/PUMP- NEIN WEU. ('11 3 WS.L REPLACEMENT Q 06MUCTtON a PUMP INSTALLATION Q SYSTEM REPAIR ❑ OTHER C3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD_ . PROP.'UNE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open 8attom ' CC Manteca Dia. of Well Excavations 10 iAr-h Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing iy(' Specifications 1`1 Public 171 Other CI Delta Depth at Grout Seal s�� Type of Grout T I I Irrigation c12—Apprax. Depth I I Eastern Sudace Seal Installed by Repair'Work Done ❑ Type at Pump H.P. State Wark Darts wall Oestrucrian ❑ wall Dlametm " Searing Material (top SWI Depth FtMw Metand teelow 561 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I OESTRUCTION 11 (No septic system permitted if put6c sever is aysilabie within 200 foot.) i . lnstidation will sere: Re6dertee Commercial= ComerciaOther ` Number of!'living units: Number of bedrooms r Charaetar at soil to a depth of 3 feet: Water table depth {� SEPTIC TANK ❑ Type/Mfg CapNo. climpnrun.rtcs v` PKG. TREATMENT PLT.❑ Method at Oisposai v . " Durance to nearest: Well Foundation Property Line' � n( LEACHING UNE ❑ No. b Length at tines Toad length/site t' FILTER eED ❑ Distance to nearest: wag Foundation Property Lure fa SEEPAGE PITS I I Oepth Size Number SUMPS 0 Distance to nearesa. Wen. Foundation Property Lin) DISPOSAL PONOS ❑ ' I hereby cernty that I have prepared this application and that the work will be done in accordance with San Joaquin county ordirwtges. state laws, a64 rules &6 1 regulations of the San Joaquin"Local Health OFstrM. Home owner ar licensed agerrr s signamre certifies the fallowing: 'h cormly that in the pedbnaance of the work far which this permit is issued. f shad not employ any person in such manner as to become subject to workman's camponsatim laws of California."..Contracsgf3 hiring or sub-contacting signature csrtifiai the fodo+wing:"1 certify that in the performance of the work for which this permit is issued,1 shag employ parYaaa suliiect to workman's comoensa- tion laws of Calitornia." The applica r ust all toe all ed i Diana. Compiete drawing an reverse side. y 1 k Signed X ride: Data: t` FOR DEPARTMENT USE ONLY -116 Application Accepted by Octet Ara Pit or Grout Inspection by Oats Foal Inspection by Oat* AdditionalComments: ❑ Stk y 466-Ml ❑ Lodi 3693621 ❑ Manteca 823-7164 p Tracy 8*4= .applicant . Return all copies to: Environmental Health Permit/Sr rvices 1601 E. Hazelton Ave., P.O. Box 2044, Stk., CA M52DI FEE AMOUNT OIJE AMOUNT REINITTED" Sit RECUVED BY OATI F"hialt'NO.