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APPLICATION .FOR PERMIT Y SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA }} Telephone (209) 466-6781 IPERMIT EXPIRES TYEAR FROM DATE ISSUED 1 (Complete in Triplicate) 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 Districts ,1 r 2 2 alp x 33� Job Address City J Lot Size PM ." _ A _ rX Owner's Name f ��.�� Address V _ Phone i. V Contractor ` ddress�� License No97TJ� Phone, +�- «TYPE--OF-WELL/PUMP:_NEW WELL_❑,._., :WELL..RERLACEMENT❑�OESTRLIC TION, [� - :PUMP INSTALLATION ❑ YSTEM REPAIR ❑ '=DISTANCE TO NEARES :'ISEPTIC TANK ' — SEWERI S DISPOSAL FLD. PROP. LINE o AGRIC TURf WELL — OTHER WELL PITS/SUMPS r , ' INTENDED USE TYPE OF WELL PROBLEM ARE CONSTRUCTION SPECIFICATIONS �f ❑ Industrial ❑SOperq-Bottom. C Manteca�; :` 'Dia- of Well Excavation,* 'qz r''t Dia. of Well Casing }❑ Domestic/Private Q Gravel Pack' t-, ❑ Tracy Type of Casing ` Specifications i F] Public;f,1 %� ❑ Other * }* C7-Delta Depth of Grout Seal Type of Grouti at a s! 11 Irrigation',1� �_Apprpx.,Depth„l.h.l-Eastern___Surface.Seal Installed by - RepairWork'Done ❑, Type of Pump' H.P. State Work Doneil' Well D.estruction L7 Well Diameter Sealing Material (top 50') f]epth E Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 101' REPAIR/ADDITION I i DESTRUCTION I i iNo septic system permitted if public sewer is , available within 200 feet.) Installation will serve: ResidenceCommercial_ �1her A , dI Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: t Water table depth ' SEPTIC TANK _❑ Type/Mfg I _ w u rt capacity a'^, Nor,'Compartments PKG. TREATMENT PLT. ❑ Method of Ois sal 'A �” t Distance to nearest: Well!�_ Foundation Pmpt rrty Line At- t LEACHING LINE ❑ No. & Length of lines ength/size%__, � r F FILTER BED ❑ Distance to nearest: Well Foundation Property kine _ t SEEPAGE PITS i I Depth Size Number O SUMPS Cl Distance to nearest: Well Foundation Property Line �# DISPOSAL PONDS ❑ i 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.' Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issuedald not { employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contractingtisignature 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." s FJ The applicant ust call for all r wired ins ctions. Complete drawing on reverse side. Signed Title: r Date. t 1 1 W'FOR DEPARTMENT USE ONLY j - l / r` 2 Application A cepted by �Z� Date Area r TWD /n O/C 16-17-98 /n { .Pit or Grout Inspection by ate F nal I ction bv, 1 Date w Additional Comments: tt el f ❑ Stk X466-6781 ❑ Lodi 369-3621. { ❑ Manteca 823-7104 D-Tracy. 835-6385 0".4— an" .4- Applicant - Return all copies to: Environmental Health f ermit/Services 1601 E. Hazelton AveP_O. Bax 2009, Stk., CA 952017k f, J -. O FEE. AMOUNT DUE AMOUNT REMITTED CK s RECEIVED BY DATE PERMIT'NO. INFO CASH ---..+-fH-t324-CREV.I i-K-5Y -.nom. ... .-.�.� -C -�--��-.,-,. -_,.11-fA-Ol.- ...�+�a.F+.^...�....,.�- to/- 0 ...EH'td-29 44�� ✓ ^ I 1