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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .j . (Complete in Triplicate) Application is hereby made to the San Joaiquin 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. " ' k Job Address 6"777- �Ll At�s� � �" City �TLot Size Qa � PM A� t , owner's Name d Address Phone \11, Contractor ��' v f � Address_P/J a6X /3- --License No Phone TYPE,OF WELL/PUMP: NEW WELL ❑ WEU_'REPLACEMENT�❑ DESTRUCTION ❑ - , _.P_UMP-INSTALiAT10N❑ SYSTEM REPAIR-❑ w _= OTHER ❑ �* DISTANCE TO-NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE "FOUNDATION AGRICULTURE WELL OTHER WELL '. PRITS/SUMPS INTENDED USE TYPE OF WELL �PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ❑ Industrial ❑ Open Bottom (I Manteca Dia. of Well Excavation Dia. of Well Casing 1 ❑ Domestic/Private ❑ Gravel Pack ❑.Tracy Type of Casing Specifications F1 Public ❑ Other # ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth 1.1 Eastern Surface Seal Installed by _ Repair Work Done Ll Type of Pump H.P. State Work Done_ € Well Destruction ❑ Well Diameter Sealing Material (top 50') 0 'yam Depth Filler M ow 50'1 1' ,\ TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR DDITION 1 DESTRUCTION'! I (No septic system permitted if public sewer is \\ * ^' available within200feet.) !^ q Installation will serve:' Residence Co.ti .rcial Other �36 7 `�lr Number of living units: Number of bedrooms 'L, .�—•+ Character of soil to a depth of3 feet: +NC�� -�_Water table depth Q r SEPTIC:TANK,'';,: - )10"--type/Mfg � Capacity,— r°� No. Compartments `PKG. TREATMENT PLT. ❑ r * a Method of Disposal h`t Distance to nearest: Well Foundation ' Property Line S y i LEACHING LINE Cl No. & Length of lines t Total length/size FILTER BED Distance to nearest: Well 110 Foundation fZ�'" Property Line SEEPAGE PITS I 1 Depth— Size � t ' �'Number ` e SUMPS L7Y - � 'Distance to nearest: Well F`undatio�"t Property,line � DISPOSAL PONDS ❑ 4 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 1 rules and regulations of the San Joaquin Coca[Heaith District. r Home owner or licensed agent's signature certifies the following: "I certify.that W the performance of the work for which this permit is issued, I shall not employ anyperson. such manner as to become subject to workman's.compensatian laws of California-"Contractor's hiring or sub-contracting signature certifies the folio n : "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 Cali r la." The applic t call fi 11 requilu sec plete drawing reverse'si Signed Title: te: 3 �� t.. '_k , l FOR DEPARTMENT USE ONLY -r �T Application Accepted by s Date Area 4{ Pit or Grout Inspection by ' Date !Final Inspection by /� Date 2" Additional Comments: Magog !Y S /Jew g2 ZA ❑ Stk 466-6781 EJ Lodi 369=3621-- Lj—Manteca 823-7 04 -D'Tracy 835-6385- 9 J Applicant - Return all copies to: Environmental Health Permit/Ser'vices'1601 E. Hazelton Ave., P.O Box 2009, Stk., CA 95201a�tla�K.J FEE AMOUNT DUE ' AMOUNT REMITTED CK CASH RECEIVED liY ., PATE PERMIT'NO. r INFO ♦.EH 43-241REV.ti1451 `�� ,/.1' I -- .- - - -- _ -�Mw =�i EH 14-26 [ f�•�/dL��tf[/�L k � t!/ �..I ,C i •