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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E..HAZEI_T ON AVE., STOCKTON, CA Telephone (209) 466-6781 . PERMIT EXPIRES 'I YEAR FRONT .DATE ISSUED �. lt' ° n,.,'_§i1� .M` .s_`: "'�. +• °3}:.#-" a'+a; (Complete in Triplicate) e 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 w1th.San Joaquin County Ordinance No:549 for s6wags,or No. 1862 for well/pump and'the Rules and Regulations of the San Joaquin Local Health District. l Job Address —.eg S G , ''`� r :.. w •. O y 33k'! r CityLot Size A// r PM Owners Name e C i ! C77 Address _r5�K9 5 �y rf' yi '# ,Phone { y Contractor's Nameicense-No. _yr — / Phone TYPE OF WELL/PUMP; it NEW WELL ❑ "j. 'WELL REPLACEMENT Ci DESTRUCTION ❑ PUMP INSTALLATION ❑ J".'" SYSTEM REPAIR C7 OTHER ❑, ! r. DISTANCE TO NEAREST: SEPTfC TANK' SEWER LINES DISPOSAL FLD. — PROP. LINE- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom' ❑ Manteca Dia. of Well Excavation Dia. of Well Casing T ❑ Domestic/Private ❑ Gravel Pack ❑"Tracy Type of Casing_ Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type'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 501) Depth Filler Material (Below 50') t TYPE OF SEPTIC WORK: NEW INSTALLATION 181' REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r available within 200 feet.) Installation will serve: (Residence—,Y-- Commercial "--Other " L�-A I Number of living units:�. Number of bedrooms , 1� `Ldihr- Character of soil to a depth.d.3 feet: CL _-�� - . Water table depth { n SEPTIC TANK Type/Mfg PYA .0 Ca�yc Capacity ��Gb 6r1V, No. Compartments % wS PKG. TREATMENT PLT:❑ g ' Method of Disposal _ Distance to nearest:` Well Foundation Property Line o " LEACHING LINE ® No , . & Length of lines y— go Total length/size 3-70' FILTER BED ?❑ 'Distance to nearest: Well Soo" _Foundation oo' d o N rax- f Property Line /P SEEPAGE PITS X 'DepthSize= 6 �f 'j Number c� "SUMPS ❑ Distance to nearest: Well " Foundation Property Line l DISPOSAL PONDS ❑ t 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 of 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 or sub-contracting signature certifies the following:"I certify that in the performance of the worVfor which this permit is issued,i shall employ persons subject to workman's compensa- tion laws'of California." - .. , itI The applicant must call for all required 10 Signedinspections. Complete drawing on reverse side. ` } , Title: Date: ,q .Z FOR DEPARTMENT USE ONLY Application Accepted by �� .Date Area C, 1 '�Z PR or Grout lnspection 6y "Date 41' y , Final`Ins ction b �,,.,.e•-_ r Date �J Additional Comments: rle ❑ Stk -466-6781- — O Lodi f 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 —� Applicant- Return all copies fo:Environmental/H aIth Permit/Services 1601 E. Hazelton Ave., P.d.- Box-2009, Stk., CA 95201 FEE AMOUNT'DUE ` AMOUNT REMITTED CK RECEIVED BY INFO_ CASE{ DATE PERMIT`NO. f + EH 13-24[REV.10183) EH 14-28 1