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r� APPLICATION FC-r PERiI:T SAN JOAQUI:J LOCAL H"cALTH DISTRICT � —967 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. IIY Telephone (209) 466-6781 DATE ISSUED _ PERMIT EXPIRES 1 YEAR FROM O.4TE ISSUED (Complete in Triplicate) Ja rein Application Thiseaeb�icateonoisthe madeSan inocompliance withlSan District ln countypermit Ordinance construct for sewagesorlNotH1862rfor ewell/pump described. PP and the Rules and/RS application the J/o/� n Local H t District. /N / Job Address �division Name v one � Owner's Name �.� Address S 7 Phone License (� Contractor's Name No. t NE1J WELL WELL REPLACEMENT �I DESTRUCTION U TYPE OF WELL/PUMP kRK: ❑ OTHER PUMP INSTALLATION ❑ SYSTEM REPAIR 17U DISP05AL FLD.SEWER LINES PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS FOJNDATION i AGRICULTURE WELL �—�— i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottum Manteca Dia. of Well Excavation ❑ Domestic/Private Gravel Pack [�Tracy Dia. of Well Casing" ❑ Public [{ Other ❑ Delt Type of Casing EasterSpecifications i Approx. L_ irrigation PP ❑ ❑ Cathodic Protection � Depth Depth of Grout Seal Geophysical Type of Grout ❑Other Surface Seal Installed by IN Type of Pum H.P. State Work Done 0 Repair Work Done G YP P kScaling Material (tap 50') Well Destruction ❑ Well Diameter Depth Filler Material (Below 50') \ sewe bl i TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/.ADDITION ❑ (No septic tank or seepage pit avaelableewithinu200cfeet.) is c� Other \� Installation will serve: Residence Commercial �� a�� jf Number of b r ms Lot size 1> era I4 Number of living units: Water table depth Character of soil to a depth'of 3 feet: No. Compartments 2 1� O� i SEPTIC TANK �j Type7Mfg � Capacity Capacity Method of Disposal r€ PKG. TREATMENT PLT. Type/Mfg — Foundation Property Line SEWAGE SYSTEM Distance to nearest: Well y DESTRUCTION �� x Z i Total length/size � LEACHING LINE No. & Length of lines s FILTER BED ❑ Distance to nearest: Well S� foundation Property Line Size �� Number SEEPAGE PITS Depth V7— lProperty Line ��d k Distance to nearest: Well �(ZO/ Foundation S� SUMPS LJ DISPOSAL PONDS �1 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 rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this I 'I certify that in the performance of the work for which permit is issued, I shall not employ any person in such manner as to become subject to workman compensation laws of California. Contractor's hiring or sub-contracting signature certifies the following: this permit is issued, I shall employ persons subject to workman's compensation laws of California." 1 t The applicant must call for all required inspections. Complete drawing � reverse�ide. Date: . T Title: �f��' Signed X / fir/ - R RTM T USE ONLY Area � Stk 466-6781 Application Accepted by , Idf'l�J Abp —�— ❑ Lodi -3621 Additional Comments: r.# 1 - U Date ,Q�fx�-; Manteca 823-7104 Pit or Grout Inspection by Date -/�'�� ❑ Tracy 835-6385 Final Inspection by r Applicant - Return all copieto: Envirormental Health Permit/Services 1601 F. Hazelton Ave., P.O. Bax 2009, St k., CA 95201 s. RECEIVED BY DATE PERMIT NO. FEE BASE AMOUNT DUE AMOUNT REMITTED ��0 � INFO �� 2 �3 4 10/SZ 50D EH 13-24 REV. 10/82 14-26