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APPLICATION..FOR. PERMIT SAN JOAQUIN:LOCAL.HEALTH DISTRICT 1601 E.,HAZE`TO,N AVE., STOCKTON, CA Telephone {209} 466-6781 1 w -,a(7-,.3r, }.1:1 't" ;;.I :R .,k !'PERMIT EXPIRES:1YEAR FROM DATE.ISSUED...I r, 3,c1S"'1:(Complete,in!Tripli.cate)',.,�4ii�.i t£ '.i1`JiI.�`'° i ,-. .'�tZSEa - .€` ' yr.•' _1'r € 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 forwell/pump and the Rules and Regulations of the San Joaquin Local Health District'701tarl,M, L41,1 �'? .;� ` ash ;Ir IQ ? "tt, i"'` ' p tr .,L , r-or9k 2'#� p ,af! c. lO Job Address fy'r66, t'°�' ��+9�'YIWO n --� City Lot Size PM ~Owner's Name Mr 1%�7' 4►S" J6AY/ 'J Address ��1� J�✓ /�i c�C��P /Qcl" Phone Coniractor's'Name ; I /V fi✓ !-V-fON.T...:License No.--9-�i/%,� ��-.T- `Phone TYPE OF:WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ � OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK) SEWER LINES I DISPOSAL FLD._ i PROP. LINE ► FOUNDATION AGRICULTURE WELL OTHER WELL ' PITS/SUMPS F INTENDED USE TYPE'OF WELL- PROBLEM AREA! CONSTRUCTION SPECIFICATIONS ❑ Industrial! ❑ Open Bottom -❑ Manteca Dia.;of Well Excavation Dia. of Well Casing _ ❑ Domesticf/Private ❑ Gravel Pack ❑ Tracy F Type of Casing Specifications ❑ Public ❑ Other. # ❑ Delta Depth of Grout Seal Type of Grout- ❑ Irrigation __�_4pprox,: Depth ,❑ Eastern 'Surface Seal Installed by i Repair Work Done ' ❑ Type of'Pump H.P. State Work Done Well Destruction ❑ Well Diameter i Sealing,Material [top 501 Depth } Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW.INSTALLATION X REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 00 #' available within 200 feet.) 6- i Installation will serve: ' Residence j Cbmmercial_ Other7 1 t 6 1 i Number of living Lnits: Number of bedrooms Character of soil to a depth of 3 feet: z'Ax Water table depth 8" SEPTIC TANK ® Type/Mfg Pye GAs'7' Capacity yde No. Compartments 3 PKG. TREATMENT PLT: ❑ i" Method of Disposal Distance'to nearest:' Well '�, Foundation- Property Line LEACHING LINE � -No. & Length of lines _ �� _ Total length/size.t i FILTER BED ❑ .distance to nearest: _ Well -Foundations f Property Line SEEPAGE PITS ElDepth { Size Number - u- SUMPS - -�❑ 'Distance to'-nearest; "Well"'- ' � ";,Foundation Property Line - DISPOSAL PONDS ❑ �- 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 LA 'i Health bistrict;" Home owner or licensed agent's signature certifies the following: "I certify that in'the berformance of the work for which this permit is issued;I shall not s `employ any person in such manner as-to become subject to workman's compensation laws of Caroornia."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- 1 ition laws'of California. The applicant must Call for all required inspections. Complete drawing ion reverse side. r Signed.. - Title: , _ - Date: !�'t"•?" = — Application Ac � � All, R DEPARTMENT-USE ONLY A _ pp cepted by; % ' Qate MArea o Pit or Grout Inspection by Date Final Inspection by Date I Additional Comments: ' s ❑ Stk 466-6781 w❑ Lodi 369-3621--t - ❑ Manteca -823-7104 ❑_ Tracy 8355-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. H za alto;Ave., P.O. Box 20M, Stk,-CA 95201 FEE' 7AMOtJNT DUE ' Y AMOUNT REMITTED CK RECEIVED BY DATE. PERMIT"NO. INFO CASH , + EH 1324{REV! 16/831 EH W28 -4�q 1 1