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li APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA � o Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ��N 9 X88 t (Complete in Triplicate) ENVIROMENTAI. HEAL H Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work �qfd�JVPkicatian is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules a an Joaquin Local Health District. { Job Address Q -�O City Ste'/ Lot Size PM Owner's Name LLi ( LL Address 5.40" Phone -3a Contractor FL-�� �Lrl��i. F Address License No..�Z�- Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 41 FOUNDAT.JON. — -- AGRICULTURE-WELL. '^^-OTHER WELL. - = MTS/.SLlMP_S__, INTENDED USE TYPE OF WELL PROBLEM AREA\ CONSTRUCTION SPECIFICATIONS ❑ Industrial I{' ❑ Open Bottom ❑ Manteca k'3 `Dia. of Well Excavation Dia. of Well Casing [71 DomesticlPrivate # ❑ Gravel Pack ElTracy Type of Casing Specifications 11 Public t ❑ Other ;. ❑ Delta Depth of Grout Seal Type o1 Grout --- 1 1 Irrigation Approx,rDepth I 1 Eastern Surface Seal Installed by - Repair Work Done ❑r- Type of Pump H•P• State Work Done — aQ Well Destruction ❑ Well Diameter J Sealing Material (top 501 Depth f Filler Material (Below 50•i TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1.1 DES T CTION l`I,(No septic system permitted if public sewer is <- f available within 200 feet.) y s Installation will serve: Residence✓ Commercial— Other ��j(� Number of living units:L--/— Number)of bedrooms �� 1 Character of soil to adept of 3 feet: ttle-depth -^ Water ta SEPTIC TANK T}rpe/M1Af g.1: E- 1 y t 3Capa ity d�' "`No. Compartments PKG. TREATMENT PLT. ❑• 4 �� " .r. Method of Disposal Distance to neatest: " Melt 13d�:_ Foundatii n / Property Line n LEACHING LINE i No. & Length of lines - �• Total length size 4,. Z FILTER BED E] Distance rto nearest 1 Well ,J.Od'°� Foundation Q Property Line /9 SEEPAGE PITS Depth _l2�! � 3y, �� Number SUMPS t Ll DistanceW to nearest: ell /4a0.�' Foundationt_7� Property Line �"'"DISPOS L PONDS ,Y ❑ �� fi I hereby certify that I have prepared this,application and that the wo'rk,will be done in ac_cordanee with San.Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Districi3} �, �' ■ Home owner or licensed agent's signature certifies the following: 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 laws 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 California.,'' The applicant must-tali for all required-inspections. Complete drawi` ng on reverse side: 1 f t Signed X ; "Title: T Date: i \ .FOR-DEPARTMENT USE ONLY/ Application Accepted by Date Area Pit or Grout Inspection by Date Final inspection by ,,(__ d�� — Date Additional CommenTs:,.` ❑ Stk 4f36 67$1 ! ❑ Lodi 369-3621 r ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 t CK 4 FEE AMOUNT DUE' I AMOUNT REMITTED CASH-._ RECEIVED 9Y DATE PERMIT NO. INFO -- r s + EH 13-24)REV.+/n 5f ��" � a(1-13Z-13Z 5 EH 14-28