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�-,V-�0 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTO , # CQD �, C Telephone (209) 466-6781 VI` TT PERMIT EXPIRES 1 YEAR FROM DATE IAWIJtA p qqls (Complete in Triplicate) �� Application is hrneby made to the San Joaquin Local Health District for a permit to construct and o I t# -- -4—G UV This annfi ation is made in compliance with Sari Joaquin County&OrdinaNo. 549 for sewage or No. 1862 for well/ u t Rules and Re u tionsof the San Joaquin Local Health District. � �� 4 (� MJob Address —__—__ __ ____._ City f Lot Size PM _ F69 2 Owner's Name Ad/lress � Q—Y_ hone Contractor _-_ _ , • ddress 1 QJ�� _. License No. Jv Phone�7 Z TYPE OF W1 I /PUMP: F NEW WELL ❑ W, LL REPLAQEMf�NT CI DESTRUCTION ❑ PUMP INSTALLATION O SYSTEM REAIR Cl OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ +-__ DISPOSAL FLD.' PROP. LINE�_ FOUNDATION AGRIC LTUR ELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS _ f I I Industrial Ll Open Bottom F1 Mante Dia. of Well Excavation __ Dia. of Well CAsing ri I I Domestic/Private Cl Gravel Pack O Tr Type of Casing ASpecification'S � " I Public f 1 Other I elta Depth of Grout Seal Type Of,Grout I ! InitLrunn ____ Approx. Depth I I Eastern Surlacq„Seal Installed by �f _ Repair Work Done (] Type of Pump H __ State Work Done _ f Well Destruction 11 Well Diameter S aling Material (top 50.1 r Depth F Iler Material (Below 50'1 TYI'l OF SEPTIC WORK: NEW INSTALLATION V REPAIR/ADDITION I I DESTRUCTION I I (No septic system dermitted if public sewer is available within 20(k feet.) Instaflation will serve: Residence Commercial Other Number of living units: _ Number of bedrooms— Character of soil to a depth of 3 feet: AWater table depth _ SEPTIC TANK F1 Type/Mfg Capacity_ No. Compartments PKG. TREATMENT PLT. Cl - � �1 4it— Method of Di osal�Distance to nearest: Well s�-ToundationProperty Line-1 t CACHING LINE Ll No. & Length of lines V V M A J Tgtj length/size Fill TFR RED Ll Distance to nearest: Well_ oundation Property Line SLILEAGE PITS I I Depth Size _ Z4_ J17 _ Njjrgber S W, PI-, (1 Distance to nearest: Well I �� oundation Property Line PONDS L] _1V_ 1 heathy certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinqpces, state laws, and rules and regulations of the San Joaquin Local Health District. r� 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, I shell 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant n st call for ctions. Complete drawing on"reverse side. r .I Signed X _-- Title: rlil.^ Date: 0_ 3 FOR DEPARTMENT USE ONLY Application Accepted by Zl� at�t/�_ Date A Pit or Grout Inspection by Date Final Inspection by Date/ Additional Comments: K -�-a J -,. nkL_ [.I Stk 466 6781 ❑ Lodi 369-3621 10 Manteca 823.71 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f l i ItJFO AMOUNT DUE AMOU T REMITTED CK RECEIVED BY DAT PERMIT NO. Vii/ �- • EH 17?I IRfV • H� ,-��/ / / // / 6�T ( /�� iy" v� �t •rte EH 14;a