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APPLICATION FOR PERMIT —� SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZEL T ON AVE., STOCKTON, CA �b Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED z. (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 District. 4 Joh Address � • MOU -rA)N W City � Lot Size Ch ACO!E PM '774(- Owner's 7`Y -Owner's Name'R®«u T L it A j,.j71ddress • i��k&K— e--r-• ``J'-"= Phone Contractor's Name License No. Phone TYPE OF WELLIPUMP: NEIN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION-0 PUMP INSTALLATION ❑ J4AQ 1 SYSTEM-RE A ❑ OTHER 'F" DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' V DISPO�SSAL TLD• Y PROP. LINE l: FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I f l ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavationes E y I Dia.rof Well Casing W 11 Domestic/Private El Gravel Pack ❑ Tracy Type_of,Casirig ► Specifications �3 1:1 Public ❑ Other Delta Depth,of,Grout S1 �. ._ ._1 Type of Grout I ❑ Irrigation --Approx.,Depth ❑ Eastern �r Surface Seal;Installed b i s:t ,..A :rtes utas 3 E F { Repair Work Done ❑ Type of Pump - A. • State Work Done'f-- Repair i x * _ Well Destruction ❑ Well Diameter 611(Sealing MatenaLitap Depth I •*kA7 ��FiRe�Material {Below 50.1 I ;;TYPE OF;SEPTICa:WORK: f� INSTA_ LLATION RE AIR/ADDITION-❑ DESTRUCTION E INo septic system permitted if public sewer is e I iJ'�1.:ltsrt 1. - '�•` d -', t `r +` '3 is i S .available;within200feet-dj,,r,,r��j• e I t : rinstallation wiEliserye �Aesidence� Commercial Number of living units: Number of bedrooms -- Water table dep h `T� It �', • I Character of soil to a depth of 3 feet: ' SEPTIC TANK 17TypelMfg X13. ::� _-' Capacity �� _ No. Compartments ' i 4 Method Disposal PKG. TREATMENT PLT. ❑ 1 I`_ f pi ) Distance to nearest: Well a Foundation _= Property Line:• F t .:�- � �*°r . I 6 . LEACHING LINE ❑ No. & Lengt hof lines y f ` Total length/size FILTER BED ❑ Distance to nearest: .~+ Well 1 flD Foundation t Property Line SEEPAGE PITS Cl Depth Size t, b ~Dumber SUMPS ❑ Distance to nearest: Well Foundation 1 Prgperty.Line s DISPOSAL PONDS ❑ 1 f t t t I T t I hereby certify that I have prepared this application and that the work will be done in a'ccory�dance.witK_SanfJoaquin 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:K I certify that in the_perlordrlance of the work for whit ythis permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub contracting signature certifies the following:"I certify that in the performance of:the work for which this pWrmAs issued, I shall employ persons subject to workman's compensa- tion laws of California." l G rJ. r ►a . The applicant m caAfojarequilli~ pections. Complete drawing on reverse side. Signed 0 Title: ��y -_Date: f FOR DEPARTMENT USE ONLY p Application Accepted by Date 1 '2 3 r � Area d 7 f .� Date Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104' ❑ Tracy 835-6385 l Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE OUNT DUE f ti AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. INFO. f S/ +EH 1324(REV.101831 �`� Igp3 �"''` �•Z.7/� L"L Y d EH 1426 I