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APPLICATIONFOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZEL T ON AVE., STOCKTON, CA (}1 <br />Telephone (209) 456-6781 <br />r <br />I' <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />II (Complete in Triplicate) <br />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 <br />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 <br />Local Health District. <br />Job Address City / lot Sae rs�'� PM <br />Owner's Name_ "pd �e� a�r_yv� V Phone <br />Contractor �" ��.._�Address ` /L License No. <br />TYPE OF WELL/PUMP: y NEW WELL ❑ WELL -REPLACEMENT ❑ DESTRUCTION O 1 r <br />-- ----.- -—Pl-MP-INSTAL-LATION,❑�,SYSTEM-REPAIR—G-- ""'"""OTHER❑~'--- J <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE l <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />INTENDED USE <br />TYPE OF WELL <br />PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />RECEIVED BY <br />❑ Industrial <br />} <br />C Open Bottom <br />C3Manteca Dia. of Well Excavation <br />Dia- of Well Casing <br />El Domestic/Private <br />11 Gravel Pack <br />❑ Tracy Type of Casing__ _ <br />Specifications <br />❑ Public <br />❑ Other ii <br />❑ Delta Depth of Grout Seal <br />Type of Grout <br />❑ Irrigation <br />—Approx. Depth <br />-0 Eastern r.�� Surface Seal Installed by <br />Repair Work Done ❑ <br />Type of Pump <br />v H.P. _'> ~ `:State Work Done <br />f <br />Well Destruction :1 <br />Well Diameter <br />_ <br />tl� - SeaFng Marterial (top�501 r yt-°t <br />. <br />Depth ^^' Filler Material {Below 50')."" - <br />TYPE OF SEPTIC WORK: NEW INSTALLATION;❑"-REPAIR/ADDITJON DESTRUCTION q INq,�septic system permitted if pubiicisewer is i <br />{ ;-• 80ailable within 200 Beet.) <br />a4.R.q i <br />'Installation will serve:. Residanc4 Commercial- Other,; y"� QIO•' x �Ge <br />Number of living units: Number of bedrooms <br />Character of soil to a depth.of 3 feet:. __ � �--Wafer,table depth <br />SEPTIC TANK .Type/Mfg ea?ll • Capacityl�"� i No. Compartments <br />PKG`,TflEATMENT PLT. l 3 i �- �.j �, ° !Method of Disposal <br />Property Line a� <br />Distance .to nearest:_ Wall" - � Fbuhdation � <br />LEACHING LINE ❑ No. & length of lines "tr Q _�� Total length/size t <br />t <br />FILTER BED C3 Distance a to, nearest:. . Well..ad un <br />Fodation _ Property Line /r] <br />SEEPAGE PITS ❑ D h,Ii —Size % 4y /0 Number <br />r i Pro <br />SUMPS 1stance to nearest: Well foundation party Line T <br />DISPOSAL PONDS <br />1 hereby certify that I have prepared this application and that the work willille done in accordince with San Joaquin county ordinances, state laws, and <br />Riles and regulations of the San Joaquin Local- Health District. <br />Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, :I shall not <br />employ any person in such manner as -to become subject to workman's compensation,laws of_Cal'rfomia." Contractor's hiring or sub -contracting signature <br />certifies the following: "I certify that in the performance of the work for which this permit is Issued, I shall employ'persons subject to workman's compensa- <br />tion laws of California." ti� c <br />The appl- nt mu all for�equ speaio s. Complete drawing on reverse side. <br />Signed Title: Data: 1 <br />II , <br />FOR DEPARTMENT USE ONLY <br />Area— <br />Application Accepted by ��..+�� �►� <br />Pito rout Inspection by u ` 7 Date��"lFinal Inspection by Tyr r� Date.- <br />Add <br />ate <br />Addition�nts: <br />-giV 4fi6-6781�"`" C] 'Lodi X369-3621 -" " ❑-Manteca 823-7104 �ti" ❑`Tracy S354i385 "T - f <br />Applicant - Return all copies to: Environmental Health Permit/Services 1601~E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br />. EH 13-24(AEV. 1 X85) <br />EH 1428 <br />FEE <br />INFO <br />AMOUNT Dur:---F—AMOUNT <br />REMITTED <br />RECEIVED BY <br />DATE PERMIT" NO. • <br />`7n <br />x-73 <br />C'_ - <br />,/zq 1 <br />