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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E�HAZEL T ON AVE•, STOCKTON, CA Telephone (2091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATEASSUED (Complete in Triplicate) trt herein described. this application is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work 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. City y-rr ii Lot Size /QG��S PM Job Address Ole, 99 �� ✓ /�✓fsAg.4 S ddress.�,�=�_0:a Phone' Owner's Name.—. License No. e.,,._.. _ -_ TYPE OF WELL/PUMP: NEW WELL G WELL REPLACEMENT G DESTRUCTION El PUMP�INSTALLATION Cl j �,r SYSTEM REPAIR C7 I OTHER C DISTANCE TO NEAREST: SEPTIC TANK SEWER LINeS• .? DISPOSAL FL PROP. LINE ( LI PITS)SUMPS INTENDED USE ❑ Industrial L Domestic/ Private Public i ❑ Irrigation Repair Work Done Well Destruction FOUNDATION AGRICULTURE WELL __— OTHER WEL `-`TYPE OF WELL "PROBLEM AREA—CONSTRUCTION SPECIFICATIONS C Open Bottom ❑ Manteca Dia. of Well Excavation? ' Dia: of Well Casing J Gravel Pack J Tracy Type of Casing , r Specifications C Other ❑ Delta Depth of Grout Seal ' - Type of Grout _App*ox. Depth ❑Eastern Surface Seahinstalled by 1 1 6 r E2Type of Pump t H.P. State W_oA Done Seating Material (top 50'1 _ 1 0)? [_; Well Diameter ? — 9 11 ' f U. j Depth Filler Material !Below 5r0'1 — N t rem armitted if public sewer is I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION _1 DESTRUCTION ❑ ! o sep is syst p available withinf200 feet.! r � w Installation will serve: Residence J— Commercial _ Other �; 1 Number of living units: I Number of bedrooms _ 1c— E V, 1 y t� IIf t' 1 _Water table depth —. Charactrar of soil to a depth f 3 feet: r � r L� J No. Compartments 1i Type/Mfg _-- — Capacity-- �SEPTfCiANK i V r < Method of Disposal PKG. TREATMENT PLT`J�_� r r " 'Distance to�nearelI r esst: Weil ;�r1 Foundation ��_-- Poperty Line _ ' ` yV�l Foundation_ h/size�.4iD.t' ].-� LEACHING LINE `` `o. &Length of lines Total len t FILTER BED V Distance to nearest: �lLT! Property Line c of Numbe SEEPAGE PITS L Depth .� Size — _ r I4'`' Foundation �'"""F'i'ii'�'&'rty line SUMPS ❑ ' Oistancerto nearest: Well _ _/ DISPOSAL PONDS ❑ � v 1^ ' r. + l hereby certify that I have prepared this application and that the work will be done an',ec`c6Fdance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District`. L q ``''"e j � � Home owner or licensed agent's signature certifies the following: "I certi"atdn.the performance of., ,work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation taws of California."'Contractor's hiring bjectt workrnan'Iscompensa- signature certifies the following: "I certify that in the performance of the work for which this permit is issued, sf4l employ Pe rsons tion laws of California." ^— .,• ti...r. The applicant must call for all Pequired inspections. C plate drawing on re rse side. } t Data'77Vd9� Signed Tom' - - `-'-' �� 'FOR DEPARTMENT,1'JSE ONLY i r, r Date i Application Accepted by ' rr wT y '°�� J1 u- 4'Finai Inspection by it or Grout Inspection by Data Additional Comments: C1 Stk ~466 fi761 ❑ Lodi 369.3621 ❑Manteca Bz3 7104,,`" ❑Tracy 835-M Applicant - Return all copies to: Environmental-Health-Permit/Sei4ices 1601�FHazelton Ave., P.O. Box 20,Q,9^, Stk., 95201 FEE RECEIVED BY DATE rr trvu rvu. INFO AMOUNT DUE [:= . . Eli 13-24 (REV. 10/831 �-Si o EH 14-26 ` —7 1 4e