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''APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT :' 1601 E. HAZELTON AVE., STOCKTON, CA - Telephone 12091 466-6781 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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. 1862 for well.`pump and the Ryles and Regulations of the San Joaquin Local Health District. city"7' Lot Size' PM ' Job Address , • �c �'. l��[` f3 ,QMa-WD Z Address es" % Gam/ Phone - -Owner's Name � - Contractor�•��u��G'� Address � , / rJi9 � ` icense No. ��=r� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Q i DESTRUCTION ❑ E PUMP INSTALLATION ❑ SYSTEM REPAIR ❑" OTHER El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLp. PROP. LINE ' FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ lndustri�l ❑ Open Bottom . ❑ Manteca --Dia-. of W4- Excavations Dia. of Well Casing T e of Casing Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy YP .� y" Type of Grout ❑ Public ❑ Other ❑ Delta ` Depth of Grout Seal 11 Irrigation --Approx. Depth L3 Eastern f Surface Seal Installed by J ` Repair Work Done ❑ Type of Pump xH.P. y r State Work Done Well Destruction ; ❑ Well Diameter Sealing Material Stop 501 _4,: Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION Ll (No Sbptiwithtem permitted if public sewer is eet I Installation will serve: Residence Commercial Other # Number of living units: —/— Number of bedrooms Water table depth �G Character of soil to a depth of 3 feet: SEPTIC TANK F Type/Mfg f Capacity _1 �4-No. Compartments PKG. TREATMENT PLT' LJ gJ Method `of-Disposal `v Distance to nearest: Well Foundation Fr Property Line _—' �jr_s: 3 1T �1: To al length/size I . LEACHING LINE ( No. &Length of lines �� - �7 =. Property''Lirie..��• - FILTER BED ❑ Distance to nearest: Well Foundation SEEPAGE PITS ❑ Depth ' +" Size a PNumber ' ❑ Distance to nearest: Well Foundation — Property Line .. '"SUMPS r DISPOSAL PONDS ❑. hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county'ordiriarices state laws, and [' rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "+-certify that in the perf"Mance of the work-.for which this permit is issued, I shall not employ any person in such manner as to become subjedt to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the peiformance'of the work for which tris permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." v v f The-applicant must call fo all re fired inspections. Complete drawing on reverse side. 1 — /' - � ! Title: Signed X �� ' r OR-DEPARTMENT USE ONLY / ddr i Date/ 'A7 _ Area Application Accepted by ' Date Final Inspection by Date Pit or Grout Inspeotian by 1 r � -- / i I Allor Additional Comments: " ❑ Ma C1 Stk 466-6781 ❑ Lodi 369-3621 � nteca 823-7104 ❑ Tracy 83x6385 . Permit/Services 1601 E. Hazelton"Ave., P.O. Bax 2009, 5tk.;CA 952b1 Applicant- Return-all copies to: Environmental Health FEE. -CK#" RECEIVED BY _DATE PERMIT NO _ INFO.Egg] AMOUNT REMITTED ".CASK' --- - -: +.EH 73-24 IREV. EH 14-28 - ..