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a � 7 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH [DISTRICT 1801 E. HAMTON AVE., STOCKTON, CA Telephone (206)488••8781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Corn)lete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit tO construct end/or install the work herein descr(oed TMs appl"tEon is made in compliance with San Joaquin County Ordinance No.filo for sewage or No.1962 for well/pump End the Rules and Regulations of the San Joaquin LOCal Health District. +� Job Addrees\ � �'�( �_ City Lot Size_ PM own.rs Name` 01 Ad6w�J /� �-- — Phone -Q -' 1 Contractor Q�# Address License No. _ Phone _______ TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT L3 DESTRUCTION O PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._—_ PROP. LINE �. FOUNDATION AGRK:ULTURE WELL OTHER WILL—---- PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Industrial O Open Bottom O Manteca Ds of Well Excavation_ Dia. of Well Casing N O Domestic/Private O Gravel Pads O Tracy Type of Casing Specif"tions R S, O Public O Other O Deka Depth of Grout Seal Type of Grout O Mriparion __Approx.Depth O EaEaem Surface Seel Installed by_. k'• Repair Work Dore O Type of Pump H.P. State Work Done Well O.T-uction O Waif Diameter Sealing Motional flop 50'1 —_-- Depth_ Fran NWWT M(Below 54Y) TYPE OF SEPTIC WORK: NEW INSTALLATION EV AEPAW/ADDITION O DESTRUCTION 11 (No septic system permitted if public sewer is available within 200 feet.) G installation will save: Reaidatea A Coni men w_ Other Number of living units:__l__ Number Z Character of sol.o a depth of 3 fest: Water table depth SEPTIC TANK X Type/Mfg Oki Capacity M0 IN.. Compartments —Z i PKG. TREATMENT PLT.CJ —> 1 Method of Disposal rest Distance to nearest: West * Foundation Property Line-3W LEACHING LINE lid No.i Length of lines � —��Total length/sue I�_ FILTER BED UJ Distance to nearest: Well 00 'F Foundation nr Line r operty �Q 0_ SEEPACE PITS II Depth ---San— Number _ SUMPS Ll Dwane to nearest: Wast Foundatirre Property Line _ DISPOSAL PONLZ II I hereby certify that I have prepared this application and that the work will be done to accordance with San Joaquin county o(dinances, state laws,and rules and regulations of the San Joegtw I xal Health District. Home owner or I" 4d agent's signature certifies the following:'9 certify that in the performance of the work for which this peanut is issued,I shad not employ e- non in such msnrwr as to become subpct to workman's compere itxm laws of California."Contractor's having or surrcontrac"signature certifies• 4owing:"I certify that in the perfonnonce of the work for which this pemrt is issued.I shell employ persons subject to workman's compensa- tion laws A California.., The ag:;)16CQ inust Cal C*41r*d inspections. Complete drawing JZ side. Speed 7iti6: -- __--- Date: 42, —/0 V �+ FOR D'�hARTMENT UVE ONLY Application Accepted by 1 —__—_ Date `C) ",ea Pit or Griot _.Inspection by - P Date.__ _ Final Inspection by � ��,.�rOatt� -13-95- Additional Comments: — ( — -- — —_ ------- — Stk 466-6791 Lodi 3693621 )(Manteca 923-7104 O Tracy 8366386 Applicant - Return all copies to: Environmental Health Parnut/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FEE INFO AMOUNT DUE AMOUNT REMITTED CH RECEIVED By DATE — PE,;1A:! :40 . EH r124(REV .. QY((j I y�l ,,/ EH 1142E