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- IT APPLICATION FOR.PERIIA SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOC.KTON, CA Telephone (209) 466-6781 q, E ;PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4! s 3, .*•1 „[ (Complete in Triplicate? _ 'k 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 nty Ordinance No.549 for sewage oro.N 1862 for well/pump and the Rules and Regula} io made in compliance with San Joaquin Couns of the San Joaquin Health,District. Local Hea trict. n„„�#t!f`'� ,w - ,. .- _ � � 't � w. � ; ay V.. r. r t” TraCY a Lot Size �) acre 5 PM Job Address 2016 SoutY'MacArthur city _ - 835- 9 4 34 License No. Owner's Name Derriel�_H eS Address Phone 22225 S Corral -Hollow RR&t8`e�^ ; Phone S35-4914 Contractor's Name DESTRUCTION ❑ TYPE OF WELL/PUMP: f NEW WELL ❑ WELL REPLACEMENT ❑ 1, PUMP INSTALLATION ❑ SYSTEM REPAIR 1:1 OTHER ❑ S� SEWER LINES DISPOSAL FLD. PROP. LINE I DISTANCE TO NEAREST: SEPTIC TANK — PITS/SUMPS :. FOUNDATION AGRICULTURE WELL OTHER WELL_ ? INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing �A w :3❑ Open Bottom. --'❑ Manteca Dia. of Weil Excavation ❑ Industrial p �.� Type_of Casing Specifications fl Domestic/Private O Gravel`Pack }„ ❑ Tracy Type of Grout rc ❑ Public ❑ Other E'4}�r { C] Delta �11 '�' Depth of Grout Seal 1 pprox. Depth ❑ Easterner Surface-Seal-installed-by - ` %` ❑ irrigation � _State Work Done Repair Work Done ❑ Type of Pump q p r `f J' Sealing Material Well Destruction ❑ Well Diameter { - Depth ` � +Filler`Material (Below 50'! S -- t" TYPE OF SEPTIC.WORK:pe,-'EW1NSTALLATION'❑: REPAIR/ADDITION ❑ DESTRUCTION ❑ ;Nailabo Rti septic system Bitted if public sewer is _ omx i1.Instalaon will serve:Residence Y mec Other� �. l Number of bedrooms 6 ft. ti Number ofrliving units: SaI1t� . -*; � Water table depth t Character of soil to a depth of 3 feet:T Precast ►z.; OO al { Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg _r„ � Method of Disposal'Se t C Tank PKG. TREATMENT PLT ° '* -ft »- 41 :� 3:r T� - � . 4 0' ftFouhdation1,2._ft- "Property Line r Distance to near est: Well - _ x� ' _.s . f �'� ea. u. Total I ngth/size f LEACHING LINE ❑ No. &Length of lines 00 fFoundation^ — Property Li' 30 f t - Y FILTER BED ❑ Distance to nearest: Well� __ t " Size Number P SEEPAGE PITS ❑ Depth Foundation _ Property Line I SUMPS ❑ Distance to nearest: Weil )-,,DISPOSAL , _PONDS ❑ I hereby certify that i have prepared this application and that the work will be done in accordance wtaqrdinances, state laws, and DISPOSALwith San Joaquin county o rules and regulations of the San Joaquin Local Health District. this permit is iss e s all Home Downer or locem such manner to e certifies the f of subjects to workman's 61lowing: "I rtcompensation lify that in the awsoof California." Contractor's rmance of the work for 1hiring or sub-contracting signature J employ Y pe I ( 'certifies the following:"I certify that in the performance of tfie work for which this permit is issued,I shall employ persons subject to workman's compensa i tion laws of C ifornia." f° The appli mupt call for all re uired inspections. Complete drawing on reverse side. t Title: Owner Date: 7-j -84 Signed , FOR DEP RTMEi�tT USE ONLY t p Date Application Accepted bya ` Pit or Grout Inspection by ^�� on Date Final Inspectby bate r Additional Comments: ` i ❑ Stk 466 6781 ❑ Lodi 36'9-3621 ❑ Manteca 823-7104 Tracy 835-6385 r Applicant Return all copies to: Envirttonmental Health Permit/Services 1601 Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK RECEIVED BY DATE PERMIT'NO. FEE AMOUNT DUE AMOUNT REMITTED H � INFO +EH 13-24(REV.101831 �''� S �. ' LJ O c, - - •- - EH 14-26 a��