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�i APPLICATION FOR PERMIT Ii SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA I' I� Telephone (209) 466-6781 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) j 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 Rules and Regulations of the San Joaquin Local Health District. r /r.VeI4 _ PM �/ f jJ7j� Cit Lot Size Job Address 17��/ y ��V r � Y Owner's"Name Address *� Phone Contractor 4i2y1k,9bA1 Address _ License No. Phone TYPE OF WELL/PUMP; II NEW WELL ❑ HT1WELy REPLACEMENT 11 DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR 11OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 41 AGRICULTURE WELL OTHER WELL PITS/SUMPS i ` t INTENDED USE TYPE OF WELT tPROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open 13oitomf OU Manteca Dia. of/Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pick t r Tracy it Type of/Casing Specifications 17 Public ❑ O`t�er �� P Delta C�� j1Dept\ f Grout Seal Type of Grout _ I I Irrigation � .Approx. a0llern Surf.Ae-S8bl Installed byV.Repair Work Done ❑ Type of Pump ��I.P. State Work Done Well Destruction ❑' We I iameterSealing Material Itop J�-�De L Filler Material (Below&9 p I'� k TYPE OF SEPTIC WORK: NEIN INSTALLAITION I)1. .REPAkf;/ADDITION I I DESTRUCTION [ I (No septic system permitted it public sewer is available within 200 feet.) t+ irestaliation witl•6erve Resin ntci+ �Csl uner-is Other_ . Number of living units: 77 a Number of bedrooms Character of soil to a�depth!of 3 feet: Water table depth ' SEPTIC TANK ❑ type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT}. ❑ - Method of Disposal 1 Distance to nearest: Well Foundation Property.Line Il LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance,to nearest: Well Foundation Property Line_ iM 6 SEEPAGE PITS l I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I ❑ 11 {I I hereby certify that I have prepared thris application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 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 shall not employ any person in such manner as to become subject to workman'scompensation 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:'A= ls`s� :. -The applicant requir ' ns. Complete drawing on revers side. AV Signed X !! ` .Title: Date: L2Nr(YR DE RTMENT USE O Application Accepted b'y I ' date —V Area °I �.Q_ Pit or Grout Inspectionlby Date Final I pection by ate L. Additional Comments: 14 ", / -a ❑ Stk 466-6761 ❑ Lodi 069-362V #3 Manteca 823-7104 •❑ Tracy 835-085 4F e Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f ' FEE AMOUNT DUE AMOUNT REMITTED' CK RECEIVED BY DATE PERMIT-NO. INFO CASH ` +.EH 13-241REV.t/)15) 35 ' 1 -7-7,77-ri IP7-1-1q5 EH 1428 Ip �s