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'AIF4r1�lFvs+k�'!o'.w•�•¢•�tY]pi�'-'—.e"_ _ .. { ta� � APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT - fir. ^r 1601 E. HAZEI_TON AVE., STOCKTON, CA Telephone (209) 466-6781 .; PERMIT EXPIRES 1 YEAR FROM DATE ISSUEQ r (Complete.jn 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 incompliance with San Joaquin County Ordinance No.549 for.sewage or No. 1862 for well/pump ana�the Rules and ReWTVI ns of the San Joaquin Local Health District. 6.1 City �. Siae PM Job Address r�t'!7-a t, f Address Owner's Name PhoFie.' '^ � Contractor's Name �Tl✓s License No. '� Phone TYPE OF WELL/PUMP: 4 NEW WELL ❑ 1NELL REPLACEMENT D „ 1 1=S 13UCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 0T9ER-0 SDISPOSAL FLD PROP LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES .. pl7$/.SU PS FOUNDATION AGRICULTURE WELL OTHER WELL I INTENDED USE TYPE OF WELL PROBLEM AREA�. CONSTRUCTION SPECIFICATigN6_ as of Weil Casing ❑ Industrial ❑ Open Bottom ❑ Manteca :Dia. of Well Excavation . �❑ Domestic/Private ❑ Gravel Pack t., ❑ Tracy Type of Casing Specifications r ' tit x' pYpe of' rout' ' - s❑ Public ❑ Other , , t: Delta Depth of Grout Seal ID irrigation --Approx. Depth C3Eastern Surface Seal Installed by , H.P. State Work E)a !Repair Work Done ❑ Type of Pump _ Sealin Material (to 50'I ` V1 :Well Destruction El Well Diameter g` p r= r- i ...�--.. Depth— .—Filler Material (Below 501 74 TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION❑ DESTRUCTION (No septic system permitted if public sewer is �,._• g- ti available within 200 feet.) I - � t .� Installation will serve:._Residence _Commercial_.•Other` - ___ ,,, ,.� .-., ^r ` Number of bedrooms 'f~ i r Number of living units: 1 Water table depth. Character of soil to a depth of 3 feet' s No. Compartrllents Capacity-----,L SEPTIC TANK ❑ Type/Mfg lt Method of Disposal f PKG. TREATMENT PLT. ❑ I I Distance to nearest: Well Foundation Riroperty Line i e 1 G ' Total length/size LEACHING LINE ❑ No. & Length of lines } F ILTER BED E3 Distance to nearest: Wel! Foundation Property Line # l 1 _ 4 E j a - .� SEEPAGE PITS ❑ Depth I Size Number SUMPS ❑ .Distance Ito nearest: Well Foundation Property Line DISPOSAL PONDS ❑ '. :1 hereby certify that I have prepared this application and that the work will be done in accordance wtih San Joaquin ycountyM1ordana�nces, state law's, and rules and regulations of the San Joaquin Local Health District. issued, !shall not agent's flowing- "I certify that in the performance of the work for which this permii is Home owner or licensed signature certifies the fo employ any person in such m si n to become subject to workman's compensation laws of California-"Contractor's hiring of subcontracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall emplcfy,persons subject to workman's compensa- tion laws of California." The applicant call for all required inspections. Complete drawing on reverse e. s Date: r .� Title: Signed a r. FOR DEPARTMENT USE ONLY �r i• V r . ! Date t7 —Z Z—� ' 'Area f tApplication Accepted by r Final Inspection I Date Pit or Grout Inspection by Date Additional Comments: r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca ffi3 710a 0 Tracy 835 6385 Applicant- Return all copies to: Environmental Health PermIt/Services�l601#E.,.Hazalton Ave., P.O Bax-2009�Stk., CA 95201 � s PERMIT"NO. FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE INFO ,Fj `�/f +EH M241REV.10183? �(J a + Z � Tk—1 67 EH 1428 =j