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-.�- -- I " ° Af -� APPLICATION FOR PERMIT / SAN-JOAQUIN LOCAL'HEALTH DISTRICT • f ' 1601 E. HAZE:.TON AVE.,-STOCKTON, CA a,f4 P A Telephone (205) 466-6781 PERMIT EXPIRES 1YEAR'FROM DATE ISSUED F (Complete in,Triplicate) 1 •r. ,, - :}, „�,- .r fl ?;+.*RT1 ine; tq tApplication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install he work herein described. This applicat n is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wall/pump and the Ryles and Regulations of the S Joaquin Local Health District. - ?E I , r '+ 9i;. r .v X53 Y CiJr J. , Lot Size M #"y Job Address p Z _-1 Ctl✓!a °�O i` r 'Phone - Address . , _ . .:Owner's Name ` � honecense-,.No Contractor LES " yAddress S PE OF WELL/PUMP: _f: NEW WELL r-1WELLREPLACEMENT © DESTRUCTION ❑ TY ;PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Q .; : DISPOSAL FLD. PROP. LINE ; 4 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FOUNDATION AGRICULTURE WEL =1 OTHER WELL PITS/SUMPS l INTENDED`l1SE"�TYPE OF`WEL"L PROBLEM AREA CONSTRUCTION-SP-EGIFICATIONS-�---�-- jp Open Bottom ❑ Manteca Dia. of Well Excavation Dia.7of Well Casing S,J Cl❑ Industrial €- ° Type of Casing— 0 Speccations ❑ Domestic/Private !❑:Gravel Pack ❑ Tracy 1 l ° , T F of Grout ❑ Public, i 0 Other ❑ Delta Depth of.Grout Seal ype ❑ Irrigation ��Pprox. Depth ❑ Eastern Surface Seal!installed by H.P. i State Wo`rk`D'one� Repair Work Done El Type'of Pump -\ 4 Well Destruction ❑. Well Diameter Sealing Material stop 50'} } Depth Filler Materiah'. Blow 50'1 TYPE OF SEPTIC WORK, NEW INSTALLATION ❑ REPAIR/ADDITION LLQ-BESTRUCTION ❑ available withinNo septic e2001feetpiarmitted if public sewer is Installation will serve: Res i nce_r L�mmercial— ter € Number of living units: =Number of b drooms 11 Water table depth Charecior of soil to a depth of 3 feet: I e/Mf C [�?�C �` ^ t Capacity/dam— No. Compartments 4 SEPTIC"TANK L-�9P 9 - i PKG. TREATMENT PLT. Q ��Method',of Disposals Distance to nearest: Well Foundation-�_ Property_Line . - -"-6 i I LEACHING LINE - ' 2Y . & Length of lines �� 0 .!- ;' :Total lerigthlsize FILTER BED ❑ Distance to nearest: Well Foundation �' Property'Line } i t SEEPAGE PITS + "Depth Size • `- Number ---� SUMPS ❑ Distance to nearest: Well Foundation Property`Line .y 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 F rules and regulations of the San Joaquin Local Health District. Hama 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 nu employ any person in such manner n to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature cert the following:"1 rtify that in the performance of the work for which this permit is issued,t shall employ parsons subject to workman's compensa tion laws Cal'�fornia.11 Th plican call for V req'red i s ct on . Complete drawing o averse Si d Signed Title: Date. �- R DEPARTMENT USE ONLY ' Date � �Ll Area Application Accepted by 'nal"1h On-by� � - . nspection-by . -T — el � S lil S Additional Comments. I Q Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy Applicant--Return all copies to:'Environmental-Health Permit/Services 1601 E. Hazekon Ave.,-PA. Box 2009,-Stk.-, CA 95201' ffEAMOUNT DUE AMOUNT REMITTED RECEIVED-BY DATE PERMIT"NO.CASH- - EH 13-24 IREV.1/8 51 r - i r � � S a a EH 14-28 - - �