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1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 'YEAR'FROM DATE ISSUED r' (Complete In Triplicate) " "'.14 a Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or installthework herein describedi This"application is made H compliance with San Joaquin County Qrdinance-No.549 for'sewage or No. 1862 for welt/pump and the Ryles and Regulations of the San Joaquin Local Health District r + Job Address t y *• . . City 6bi Lot Size ' PM Owner's Name s-.""AddT"`r ✓ QQD 3 'Phone ' - Contractoryt[.C1.1G, ,Address �� k,,,j "t.3 TYPE OF WELL/PUMP: License Nphone, ' -9 NEW WELL ❑ WELL-RIPL'1ACEMENT. ET DESTRUCTION ❑ - �x PUMP INSTALLATION ❑ I �1- _ SYSTEM R�PAIR ❑ i OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK I. SEWER-LI ---.--_ ..... PROP. LINE DISphSAL FL•D,_ h FOUNDATION l t:. AGRICULTURE WELL �' } OTHER WELl;�- W PITS/SUMPS INTENDED USES TYPE OF WE!!,- PROBLEM AREA CONSTRUCTION SPECIFICATIONS E i ❑ Industrial ❑ Open-Bottom 1 E3 Manteca I ,r Dia. of Well Excavation Dia. of;Weil Casing ❑ Domestic/Private psGr vel Pack1, er Trac t s {.. _y : Type of-Casing'_'.---_- - - -� 1� +' ❑ Public ❑ Other '� y �*❑ Delta""' �'I" .-, Specifications Depth of Grout Sea[ !^ t" ❑ Irrigation _.-Approx. pe th; 1`�h 4 Type of Grout P Easternf s "" Surface Seal Installed by Repair Work Done E3TypeType of Pump is<:: f \ g 'Pj ' State _ Well Destruction ❑ Well Dia'mater t- Work Done Sealing-Material (top 501) ( I Depth+ '�.��;z h. Filler Materia!(Below 501) " TYPE OF SEPTIC WORK: NEW INSTALLA—tilON REPAIR/ADDITION;❑, DESTRUCTION 1 0, 1 . (No septic system permitted if public sewerris'; �• ' r yava+labin'elwithin 00 feet.} Installation will serve: Residence AiCoritmercisfl� ova` w� Number of living units:�� Number of bedr o Character of soil to a depth of 3 feet: t I fi. ,rlq SEPTIC TANK Type/Mfg t f . 'Water table depth I" PKG. TREATMENT PLT. Capacity io4 t IVo. Compartments 2-, i at distance to nearest: /} �� : j etpi 1-11.- ��-,--W�11 _Fou�ation "-Property Line of LEACHING LINE No.& Length of lines FILTER BED ❑ Distance to nearest:; z Total length/size Well > ,SSD " Foundation__,� Property Line s 7^- SEEPAGE PITS Depth i t ° Size " Number Z-- SUMPS ❑ Distance to nearest:` Well �/v�r�` � i ' 7 A DISPOSAL PONDS ❑ �du� Foundation�f}} _property Line_/0 1-_ 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 t8e San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:""Ice l employ any person in such manner as to become subject to workman's compensationtlaws of Californian"Contractor'swork for which or sub-contracting s permit is issued, l signature not certifiesi certifies the following:"I certify that in the p tion laws of California." $erformance of the work for which this permit is issued, I shalf employ persons subject to workman's compensa- The applicant must call for It req inspect' ns. Complete drawing on reverse side. Signed Jw Title: - Date: FOR DEPARTME T USE ONLY Application Accepted by Date Area b oftr Grout Inspection by E .� .Date a>--53� Final Inspection by • � Date 4- Additional Comments: t ❑ 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.O, Box 2009 "Stk., CA 95201 " 'k a FEE AMOUNT.DUE,,,`.__ ` INFO' '�{ AMOUN.T_REMITTED_ ASH-, •-RECEIVED-SY PERMIT-`N0. EH 14-265a o a t e++ ! s'--