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h� dS APPLICATION°FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZELTON AVE., STOCKTON, CA �f r Telephone (209) 466-6781 �] I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED U (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" 1 f Job Address ®V t f City Lot Size- p{y Owner's Nam Address ��q� _> Gvir► &U t71�� Phone C� Contract 0-Address •-� [� `� `License No3Z��Z& Phone363dd`Sr©s— TYPE OF WELL/PUMP: NEW WELL ❑ ,WELL REPLACEMENT Cl DESTRUCTION ❑ PUMP INSTALLATION_❑, - ;,,�_ SYSTEM REPAIR.,0- OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. F PROP. LINE _ FOUNDATIOTQ "� A'GRICULTURE WELL, OTHER WELL.." PITS/SUMPS { v � INTENDED USE TYPE OF WELL PRCISL'EM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑t Gravel Pack - ❑_Tracy u T e of Casin ,� YP 9 Specifications F1 Public ❑ Ot er,'S f 1.Delta�' Depth of Grout Seal _ � Type of Grout 1 Irrigation m _Approx, Depth i,l-"Eastern Surface Seal Installed-by .v Repair Work Done! 0 •.Type,of Pump H,P. State W_ork Done Well Destruction ❑ Well Diameter Sealing Material (top 50') 'n Depth Filler Material (Below 501 Ut TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I_] DESTRUCTION LI '(No septic system permitted if public sewer is '{ available within 200 feet.i Installation will serve: 'Residence Commercial Other 3 4 Number of living units.="�"Nurriber o " " droo s Character of soil to a depth of 3 feet:I Water table depth "4 SEPTIC TANK V_ Type/Mfg Capacit p 1 -�-� Y� No. Compartments a PKG:TREATMENT PLT, El # I Method of Disposal ?', 4 Distance to nearest: Well ` Foundation 10 Property Line _ LEACHING LINE No. & Length of lines ` 0 ` Total length/size X Q Co/ Property Line FILTER BED f Q Distance to nearest: {Nell p/9/i Foundation .a`� a41d , -/sus �1 "— _ SEEPAGE PITS 11t�Depth Size Number SUMPS ❑ Distance to nearest: Wel _._ Foundation /0 r a lProperty Line DISPOSAL PONDS- ❑ - -a " = 'i ''^" L - I hereby certify that I have prepared this applicatibn-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, Horse owner or licensed agent's signature certifies the following: "1 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 laws of California." Contractor's hiring or sub-contracting signature certifies-the following: "I certify thai in the'pertormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." ., The applicant m t call for all r ire Inspections. Complete drawing on reverse i Signed Title: bate: 1 C 11 Fb DEPARTMENT USE ONLY Application Accepted by Date L. Area Pit r Grout Inspection by r Date inal Inspection by 4---A Date Additional/Comments, ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 F N i FEE AMOUNT DUE AMOUNT REMITTEDCK 9 i INFO CASH RECEIVED BY DATE PERMIT NO. + EH 13-24(REV.1/e 51 3 EH,4-ze ,. 7O �Q • I . 3srs�—