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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T OWAVE., STOCKTON, CA Telephone (209) 466,6781 PERMIT EXPIRES 1.YEAR FROM DATE ISSUED (Complete in Triplicate} y madeApplication is hereby made n the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is H Health Danri-ct.th San Josquin County Ordinance No.549 for sewage or.Ro. 1862 for well/pump and the Rules and Regulations of the San Joaquin , LCocal Health district. Job Address �I City Lot Size PM Owner's Name �� I �a? T` ress Phone k3 .7 �1 Contractor's NameN�(;�L.C� r p Icense No: 2 3 7 3 Phoe TY-PE OF WELL-/ UMP. NEW WELL C7 '77, n1NELL AERf..ACEMENT ❑ DESTRUCTION ❑ i .. PUMP INSTALLATION ❑ SYSTEMIREPAIR Iii DIS TANCE TO NEAREST: SEPTIC TANK OTHER ❑ ,) SEWER LINES DISPOSAL FLD. PROP. LINE f,J FOUNDATION AGRICULTURE WE�Lf OTHER WELL 1 i INTENDED U E ..a° PITS/SUMPS S TYPE OF WELL •,;PROBLEM AREA CON STRUCTION SPECIFICATIONS ❑ Industrial ❑ Op Bottom ❑ Manteca 1�4Dia. of Well Excavation Dia. of Well Casing i,k'Domesiic/Private ❑ Gra vel Pack ❑ Tracy T ' r ❑hPublic Type of Casing Specifications ❑ OttiJ ❑ Delt9. Depth of Grout Seal ' ❑ Irrigation --Approx. D��Jjstern Type of Grout Re fair Work Done a Type of Pump _— ace Seal Installed by T y F.H.P. State Work Done ' �. 417—Well Destruction E3,0` Well Diameter r° , Sealing Material (t 50'1 i �.� ;� _ , Depth 11 Filler iVlaterial'(Below 50') l .i `TYPE OF S£PTIC WORK: "NEW'INSTALLATION C3" REPAlp7ADDITION ❑ bESTRUCTION ❑ (No septic system permitted if public sewer is Lqi ' available within 200 feet.) I `f i ( Installation will serve: Residence— Commercial Other 11 l' I fi Number of living units: I�Number of bedrooms ( 7 Character of soil to a depth of 3 feet: I SEPTIC TANK ❑ TWater table depth PKG. TREATMENT PLT. ❑ !! ype/Mfg Capacity No. Compartments 1 Method of Disposal Distance to nearest: Well Foundation �N Property Line LEACHING LINE ❑ No. &Length of lines BED Tota! length/size I FILTER ❑ Distance to nearest: Well Foundation Pq Property Line SEEPAGE PITS ❑ Depth Size Number R SUMPS ❑ Distance to nearest: Well ` DISPOSAL PONDS ID ~Foundation' Property Line 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: ! em an g: "I certify that in the performance of the work for which this permit is issued, I shall not y y person in such manner as to become subject to workman's compensation taws of California."Contractors hiring or sub-contracting signature certifies the following: "I certify that lin the performance of the work for which this rmit is issued, I shall employ tion 'laws of California." Pe p y persons subject to workman's compensa- tion aII pplicant m call r all ui inspections. Com)ete drawing o 'reverse side, SignFd �} Tide: /fir Date.. I� -- 1 FOR DEPARTMENT USE ONLY Application� Accepted by I i k 5$ t DateArea Pit or Grout Inspection by II' Date ' i — _ Final Inspection by �-�/ Date 4 Additional Comments: I� , 11Stk 466 6781 ❑ Lodi,369-3821 ❑ Manteca 823-7104 U Tracy M6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E,,+fazelton Ave., P.O. Box 2009, Stk., CA 95201: II ` r FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASE! RECEIVED BY DATE PERMIT'NO. ' t EH 1324{REV.14/83) EFI14-26 ��