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3.a� y:uo APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED" r (Complete in Triplicate) x, i 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. - � ,. i't�3 _ ,k ' .- ':� E- .. err' ,, . •., _ , Job Address City Lot'Size 3��}�� PM - Owner's Name Address' -ZZC, d C;.,s>a-a.a�' phone h Contractor' Address_ �v�r. cen�a No. S q3(0, h,,e TYPE OF WEL /P P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ^� PUMP INSTALLATION E SYSTEM REPAIR ❑ h OTHER El J DISTANCE TO NEAREST: SEp IT C`TANK SEWER LINES DISPOSAL FLD'• PROP. LINE FOUNDATIO`Nom. AGRICULTURE WELL OTHER WELL 4 `' PITS/SUMPS _ \ " INTENDED USE TYpE OF WELL _PROBLEMCAREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom: Qrr ❑.Manteca- � D.ia. of Well Excavation Dia. of Well Casing 4 I ❑ Domestic/Private ❑ Gravel Pack 4❑,Tracy Type of Casing Specifications p _ } "' AJ ❑ Public ❑ Other [# ❑ Delta Depth,off Grout Seal Type of Grout f� ❑ Irrigation �4pprox. D pth: ffEastern Surface Sealdnstalled by V Repair Work Done ❑ Type of Pump H.P. __ State Work Done r� Well Destruction ❑ Well Diameter Sealing Material [top 501 'ar Depth Filler Material (Below 501 rt``*►... _ it. TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system-permitted if public sewer is /' available'Within 01} Within 2 'feet.) f4 Installation will serve: Residence� Commercial— Other Number of living units: J�fumtier of b ro s '* Character of soil to a depth of 3 feet I Watery table depth SEPTIC TANK 9-�'Type/Mfgt _ Capacity___N)-O 0 t No. Compartments PKG. TREATMENT PLT. ❑ � "" `Me hod-of-Disposal Distance to nearest: Well Foundation Property Linel b' LEACHING LINE P�- No. & Length of lines Total length/size FILTER BED ❑. Distance to nearest: Well 9)3 Foundation�.-ALL Property Line II SEEPAGE PITS w--bepth j Size ? t� Number11_ " SUMPS ❑ , Distance to nearest:. Well Foundation Property-Line— DISPOSAL PONDS ❑ ;f . 4. I hereby certify that I have prepared this 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. � •^-- ----:�"--- •nom �- Hnrn bxVner6rIicens6d'Wgent's'signatur`e certifies the"fdllowmg: "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's compensation'Iaom 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 Calif 'a." The applicant m all for requ- in tions. Complete drawing on reverse side. Signed Title: �111�/�G�-� Date: w� OR DEPARTMENT USE ONLY ' i �+ lication Accepted by Date Area Pi r Grout Inspection by e Final Inspection by ate i Additional Comments: t ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 ? Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE .AMOUNT DUE-f. - AMOUNT REMITTED CK- RECEIVED BY DATE PERMIT'%NO. �. INFO EH;¢ze IRev.f i e 5, �--15. C� V791