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� I41 r, APPLICATION FOR PERMIT ill SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E:NHAZEL T ON AVE., STOCKTON, CA i Telephone (209) 466-6781 l� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �IM (Complete in Triplicate) i 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. i Job Address ��i/� ! 1�/ Ci� S/ City Lot Size O PM 1 Owner's Name ltfj/�7�lrJ�� /r ' /Vl/mdress 53 83 _ Fhol1 — Contract�oro�s 19 l 0b;U. t'Address _14..c7t'NdB/��(lt�L ce e iVo.�02��d=PfioneS� —�53� TYPE OF,iWELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ��+--�� 'r�.�rPUMP INSTALLyA,T�IO,fV.❑:jam; ,.� rSYSTEM REPAIRr❑W,. �. OTHER ❑_ DISTANCE TO NEAREST: ,SEPTIC TANK i r",SEWER LINES DISPOSAL FLD. `PROP. LIVE L) FOUNDATION tAGRICULTURE WELL OTHER WELL-- - `'"PITS/SUM PSr_ _ 1 INTENDED USE ,*,,TYPE OF WELL'i PROBLEM AREA CONSTRUCTION SPECIFICATIONS �+ # ElIndustrial °4 ` '❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia- of Well Casing El Domestic/Private ❑ Graver Pak � ❑-Tracy' r~ Type of Casi 51 y Specifications 1-1 Pubi4 ( l Other : FI.Delta» Depth of Grout Seal iType'of Gr6ut'— I I Irrigation Approx.,Depth l 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump " _I H.P. State Work Done Well Destruction ❑ Well Diameter " `""' " Sealing Material (top 50') t ; Depth # � r Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION)d REPAIR/ADDITION I 1 DESTRUCTION i I (No septic system permitted if public sewer is a - available within 200 feet.) Installation will serve: Residence 41. Commercial— Other Number of living units: _1_! Number of bedrooms Character of soil to a depth of 3 feet: C AAA Water table depth SEPTIC `ANK )a Type/Mfg je� x 0-k 15 u aj- Capacity DC 4o h�&o. Compartments t PKG. TREATMENT PLT. Fl J f y3t� Method of Disposal t I' 1 1! Distance to nearest: Well Foundation Property Line 30Y2-�G US 0.,4 'v:`t LEACHING LINE 0 No. & Length of lines ?0 ^��ol - _ Total length/size 2� FILTER BED LJDistance to nearest: Well rxG�L��- Z Foundation ` t Property Line i SEEPAGE PITS I 1 Depth Size Number SUMPS L-1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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, an T) 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 issued, I shall no employ airy person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signatur 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 m all quir d i ctio oo rag on reverse side. Q Signed X m tw Date: j FOR DEPARTMENT USE ONLY Application Accepted by Date 7— a Area 3 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk466-6781 ❑ 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 J k fEE AMOUNT DUE AMOUNT REMITTEDCK RECEIVED BY DATE PERMIT-NO. I INFO H +.EH1CCC!!! 3-24 IREV.r� n 5f 560 EH 14-20 i —C •� II ,