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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTUN UN AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 1 YEAR FRCM DATE ISSUED IComp;ate in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.F49 for sewage or No.1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health Distrriic�t. ' J 11C Ane —Address C ?C !sL-� r� J City,1-Ane—- Lot Size PM Owner's Name _'I 0)0 e-L� - Address _ _ Phone � e 17175 Phone -0 Contractor's Name -� Cleanse No. J TYPE OF WELL/PUMP: NEW WELL U WELL REPLACEMENT G DESTRUCTION C PUMP INSTALLATION C SYSTEM REPAIR G OTHER C DISTANCE TO NEARFST: SEPTIC TANK __-- SEWER LINES _ DISPC'AL FLD._- PROP. LINE -_ FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial C Open Bottom ❑ Manteca Dia.of Well Excavation Dia. of Well Casing _ _: Domestic/?rivate Gravel Pack ❑ Tracy Typ-of Casing- Specifications Public Other C? Delta Depth of Grout Seal Tvpe of Grout — Irrigation --Approx. Depth �, Eastern Surface Seal Installed by _ — Repair Work Done Type of Pump H.P. State Work Done Well Destruction Well Diameter Sealing Material(top 509 _ — Depth __ Filler Material(Below 50'1 _---_ -- -- — TYPE OF SEP71C WORK: NEW INSTALLATION UK REPAIR/ADDITION i- DESTRUCTION 1 ' (No septic system permitted if public power is available within 200 feet.) Installation,v;ll serve: Residence ✓Commercial Other Number of living units: If Number of bedroo s One/ Character of so'.1 to a depth of 3 feet: QAir% Water table depth SEPTIC TANK Type/Mfq _4J. apaclty_. No. Compartments _Z PKG. TREATMEN f PLT.: f t Method of Disposal Distance to nearest: Well_14ILL Foundation�5 Properly Line�e `� LEACHING LINE No 6 Length of lines Total length/sire--o- ` -- FILTER BED Distance to nearest: Wall J I�jFoundation Prope►hr Line — SEEPAGE PITS 'C. Depti, .,Z S I Size-�Ld Number SUMPS Distance to nearest: Well f C O Foundation 1 Property Li^e- Cf DISPOSAL PONDS I hereby certify that I have, prepared this application and that the work will be done in accordance w;th San Joaquin county ordinances,state laws, and rules and requiations of the San Joaquin local Health District. Home owner or licr:nsed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is Issued,1 shell not employ any person in such manner as to become subject to workmen's compensation laws of California."Contractor's hiring or subcontracting signature certitieq the follo.ving. "I cenifr that in the perfcrmance 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 aI�squired inspection%. Complete dravong onn��reverse side. I �/ Signed X.. `._ f- � // _. Title: (.LJ=vA)r�4_--.----- Date: (p FOR DEPARTMENT USE ONLY -} Ares �J Application Accepted by --- - '�-._.._-_ ---- Date pit of Grout Inepoct,on h1 __ --__.-_._-_- Date_ Final Inspection by. - =y 1_ - Date Additional Coiremunts --- ;y. . - 1 ': - 1=,-(______---- �/ Stir 466 6781 Lodi W51-3621 Manteca 823.7104 Tracy 835.6385 Apphc,,,i . Return all copim to Environmental Health Permit/Services 1601 E. Hazelton Ave.. P.O. Box 2009, Stk., CA 95201 rff T ALtOUNT DUE AMOUNT REMITTED OK RECf.IVEU BY DATE PERMIT NO. CASHFI(I fw 7 _—_