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- I APPLICATION FOR PERMIT. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES-11 YEAR FROM DATE ISSUED r (Complete in Triplicate) y 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:s#1862 for well/pump and Ryles and Regulations of the San Joaquin Local Health District. .z`tr� e.,(V ILC ' City Lot Size QM Job Address A, 900 a Lc,+►1u�t-. C" O C.O• Address fZZI E• j'1la�Y� 5�, C'hAAA3�CI O Dhone . Owner's Name `` Contractor 1 !; T Ll io b�et'f rbr, Address 106!Avvtofl W&4,11grRtcense No. " ! Phone o ! TYPE OF WELL/PUMP: NEW WELL 1-1Address REPLACEMENT ❑ DESTRUCTION ❑ , PUMP INSTALLATION ❑ SYSTEM.9EPAIR,E1_,..W,. _ ATHER.❑_ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f � %t Dia. of Well Casing ❑ industrial ❑ Open Bottom [D Manteca Qia. of Well Excavation _-_ g� Q VC- .a t S ecificationsi Q Domestic/Private , �❑ Gravel Pack ❑ Tracy Type of Casing- : - - P 3,+ yc. .� �0111 er ❑ Delta Depth of Grout Seal_# Type of Grout ❑ IrrigatioffZ_ �Pprox. Depth ❑ Eastern Surface Seal Installed by.. Repair Work Done ❑ Type of Pump H p i State WorODone �. Well Destruction ❑ Well Diameter Sealing Material Itop 501 I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION.D,INo septic system permitted if public sewer is available within 200.feei_) Installation will serve: Residence— Commercial Other x Number of living units: Number of bedrooms 4' ' r r • �' `�� Water table depth Character of soil to a depth of 3 feet], - ! SEPTIC TANKh. ❑ Type/Mfg `' Capaaty r T Not Compartments p CJs J '' Meihod'of Disposal 1 } PKG. TREATMENT`PLT. ❑ Distance to nearest: II� Foundation Property kine } yF If 'Total length/size �v LEACHING LINE ❑ No. & Length of lines ,rr.,,X.,ti E. i e_«.s.�.,..--,�rr� '•�i" r 'ti I FILTER BED 13 Distance to nearest: Well Foundation P 1 perty Line ( „ . . t SEEPAGE PITS ❑ Depths i Size Number F ` SUMP$ �'s ,.: ❑ Distance to nearest: Welt Foundation _- Property Line - p DISPOSALfPONDS, { 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, arid; ' ...i .. t . t,.*, � rules and regulations of the San Joaquin Local Health District. 1 _. �,r{�f ._ Home owner or licensed agent's signature certifies the following: 'I certify that in the performance of the work for which this permit is issued, f shall not employ any person in such manner as to become subject.to workman's compensation laws of California." Contractor's-hiring or sub-contracting signature +, certifies the following:"I certify that in the performance of the work for which this permit is issued, l shall employ-persons subject to workman's compensa . ; �+ _^ice'"7 . tion laws of California." a The applicant t call for all required inspec ns. Complete drawing on reverse side. ,a rt _ s }W x .G .Date: Signed Title: "� m }...0.wry r t i FOR DEPARTMENT-USE ONLY ` ! � s a j,y Ul7#� Application Accepted by Date + Are .i + Date 'F trial Inspection by Date �� Pit or Grout Inspection by = .70-eamp Additional Comma!", � -- Z Q Tracy 835 6385 LJ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDC RECEIVED BY DATE PERMIT NO. INFOy/� I ? + EH 13-24(REV.1/85) EH 14-26 .I� f