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4, y. y s+ APPLICtFt PERMIT � SAN JOAQUIN LOCAL-'HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) l 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.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. '7,-'9"- o[•e4 Job Address �` ` City C Lot Size J� PM Owner's Namee lei u15Address/ Y-3 a��,P.� L Phone i Contractor Address License N0 � z��Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER U M DISTANCE TO NEAREST:,SEPTIC.TANK SEWER LINES DISPOSAL F.LD.0 PROP. LINE r - * FOUNDATION AGRICULTURE WELL OTHER-WELL- -PITS/SUMPS WTENDED USE 4 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r 1 ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f ❑ Domestic/Private L7 Gravel Pack ❑.Tracy "- Type 4f Casing Specifications P Public Cl Other F H Delta Depth of Grout Seal Type of Grout 1 1 Irrigation -Approx.-Depth I I 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 `Filier Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIAODITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) 5 Installation will serve: Residence=�. Commercial - OtherY + a Number of living units: _-.-J— Number of bedrooms Character of soil to a depth of 3 feet: Un C= Water table depth SEPTIC TANK O .'Type/.Mfg- Capacity No. Compartments PKG. TREATMENT PLT. ❑ - Method of Disposal " Distance to nearest: Well 6--`�P Foundation, Property Line LEACHING LINE No. & Length of lines { Total length/size - .. FILTER BED ❑„Distance to-nearest: Well I Foundation 4c" �Property Line SEEPAGE PITS 'I I Depth /C'7 Size Number V, _ SUMPS,. Distance to nearest: Wellc2Q't ET Foundation �Property Line DISPOSAL PONDS EI ' �. , I hereby certify that I have prepared.thishapplicationtand that the work will be done in accordance with San Joaquin county ordinances, Mate laws, and rules and regulations of the San'Joagilirilocaf"Healtli Di§trict. ` 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." Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance 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 rcall for 1 requuii inspections.,.Complete drawing on--reverse side. Signed X Gti / �T/ "� - ' Title: __!tr..w.s�+. Date: One FOR PARTMENT-USE ONLY i f Application Accepted by -__- , �" - Date � Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 'Ll Stk .466:6781 ', ❑-Lodi 369-3621 ❑ Manteca 8290'Tlb4 ❑ Tracy; 635-6385 Applicant- Return all copies to:.Environmental Health Permit/Services 1601 E. Hazelton_Ave., P'O',Box 2009, Stk., CA 95201 FEE)NFO AMOUNT DUE AMOUNT REMITTED, CK CASH RECEIVED BY y 'DATE PERMIT NO. .s- EH 14-2e +.EH 13-24(REV.i/K 51 y k'. :" ',•.. .�..,..- �.,�. .... .,. - .x�` -.w... _-,T - — _ .... � 1 A