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r APPLICATION FOR PERMIT SAN JOAQUIN LO AL HEALTH DISTRICT 1601 E. HAZE T 0 AVE., STOCKTON, CA Telephon (209) 466-6781 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in 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 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. / 4�7. � Jab Address d � CityG a-591 Lot Size PM d � � C 77-i o7, . Owner's Name Tt�9 o Address Phone Contra Name t27- License No. �6 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WEL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TAiVK SEWER LINE DISPOSAL FL6. - PROF-CI—NE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE �TYPE`6`1F WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open'Boitom ❑ Manteca D a. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy qp Type of Casing Specifications £ ❑ Public ❑ Other 'n ❑ Delta Depth of Grout Seal Type�of Grout ❑ Irrigation --App rox. Depth �❑ Eastern Surface Seal installed by c Repair Work Done ❑ Type of Pump '`� H.P. State Work Done-0 1 � Well Destruction ❑ Well Diameter H Sealing Material {top 501 r Depth ` Filler Material (Below 50') - p, TYPE OF SEPTIC WORK: `NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is 1n ' available within 200 feet.) Installation will serve: Residence' Commercial_ Other Number of living units: Number`of.bedrooms r` / f.. Character of soil to a depth of 3:feet: 1AWater table depth E SEPTIC TANK ❑ Type/Mfg �� Fes. Capacity No. Compartments PKG. TREATMENT PLT. ❑ 7; � k �" Method of Disposal *} i i { Distance to nearest: ,Well Foundation Property Line t LEACHING LINE 4t No. & Length of lines Aw -0 Total length/size a t FILTER BED ? f {] Distance to nearest: Well. Mo Foundation�_-70 �' Property Line ti Zi SEEPAGE,PITS P---Dpth � r Size i Number j SUMPS ❑ Distance to nearest: Well / r Foundation /10&- Property Line fd DISPOSAL PONDS ❑ 4 I hereby certify that I have prepared this application and that the work ill be done in accordance with San Joaquinc unty 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 certi y 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,cbmpensation laws of California." Contractors hiring or sub-contracting signature certifies the following:-1 ce lify that in the-performance-of-the-work for. ich this permit is issued,-"hall-employ-persons,subject to workman's compensa, tion laws of California." �3 y The applicant must rail reci sd in S. Complete drawing o 1 r i erserside. t. y Signed Title: ) Date: FOR DEPAR M�NT,USE`ONLY Application Accepted by -----Date---u- --1-.--•t-- •--J Area v fpit) rGrout Inspection by Date Final Inspectio �� a. a Additional Comments: ❑ Stk 466-6761 ❑ Lodi W3621 1E Mante a 847104 ❑ racy 835.63- Applicant LReturn-all-copies-to:_Envir0nMSntaI-HeaIth-Permit-/Services 35.63ApplicantLReturn-all-copies-to:-Environmental-Health-Permit"/Services 1 1-E:-Hazelton-Ave:,-P.O_Box 20D9,•Stk.-FEEK ~ 1-- — -- INFO AMOUNT DUE AMOUNT REMITTED C SH ' f 'RECEIVED BY, DATE PERMiT'NO." 1.11114 13�14 EH 14-28IREV,10/831 -. S `- � `�VS 'as; -'A'CeR �,