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kr` APPLICATION FOR PERMIT t SAN J0AQUIN'lLOCAL HEALTH DISTRICT f 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES,;1•YEAR FROM DATE ISSUED (Complete in Triplicate) ribed.This application is Application is hereby made to the San Joaquin Local Health District„for a permit to construct and/or install the work herein desc made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wait/pump and the Rules and Regulations of the San Joaquin Local Health District. } Lot Size City PM Job AddressI r y� � ILdJ Phone Owner's Name [6 Y Address q f _ j Phone / Contractor T w s Address f ' '� r'_l 7 License TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 11 OTHER F-1 DISPOSAL FLD:r DISTANCE TO NEAREST'SEPTIC TANK. . SEWER,LINES PROP. LINE A OTHER WELL �,i `'--FOUNDATION AGRICULTURE WELL 1 PITS/SUMPS r INTENDED USE TYPE,OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; 'Dia. of Well Casing LJ Industrial 0 Open Bottom ❑ Manteca Dia- of Well Excavation '” T e of CasingSpecifications ❑ Domestic/Private# ❑ Grave Pack ❑ Tracy V' -T a of Grout r Cl Deliaw De th of Grout Seal yp [I Public -. ❑ Other_:�� R�.ti �r �. ? _ r I I Irrigation ---1--Approx. Depthil 1 Eastern, . Surface Seal Installed by I ` H P - State Work Done_ Repair Work Done �.0..,` Type of Pump Sealin Material h --w'1 Well Destruction ❑ Well Diameter h ` 50'1 ' ,----- ' FillertMaterialIBelow.Depth ; ! TYPE OF SEPTIC WORK: .NEW INSTAL TION I I „ REPAIR,ADgDITION. *DESTRUCTION I I aN labptic system permitted if public sewer is Installation will serve:- Residence Commercia'I=s�frOtHer r p f �Number`of bedrooms �"''4Ft � Number of living units: _ Water table depth Character of soil to a depth-of 3 feet: - Z� SEPTIC TANK �` Type/Mfg Capacity Z_ ---040 - No. Compartments Method of Disposal PKG. TREATMENT PLT.0 { Distance to nearest: Well Foundation Property.Line Z.' Total length/size - Z LEACHING LINE � No. & Length of lines r j FILTER BED ❑ Distance to nearest: Well. Foundation Property Line SEEPAGE PITS >Q Size Number Distance to n arest: Well F undationl Props Ling r SUMPS �e �G�l C T �.ilS �l(eV ?��l7leF!S'u. DISPOSAL PONDS Fa �7 � T I hereby certify that I have.preparad this application 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-Di§trict-� .�+�-.�--.-'t 3 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, 1 shalt not employ any person in suc2iinanner 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 permit is issued,I shall employ persons subject to workman's compensa- tion laws of California.,, r The applicant-must.•cal requrr spectlo Complete drawing on revs si - 1 f l Date:l i Signed f Title FOR;DEPARTMENT USE ONLY /L Date Area Applicati Accepted by Pi or -61t: Final Inspection b ut n pe tior a Datdt�O �' f$ alp` i Additional Comments: �t } ❑ Stk 466-6781 ElCodi Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy Ave.,., p, O. Box 2009, Stk., CA 95201 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton f CK RECEIVED BY :);� PERMIT•NO. FEE I fNED AMOUNT //DUE AMOUNT REMITTED CASH EH 13-21 rREV.}/N51 $✓ J EH t4-2B 1