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` •APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 q gg PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APR 19 (Complete in Triplicate) ENVIR NM NTS icauon is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the worl5 r�he San Joaquin made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/Dump and the Rul Local Health District. I ZSd S t(/t S N City 'SToqraxY Lot Size PM —_- Job Address �,.�.�, � � �• ')r �'PV Address J'»=L!1en rAt�N �" �ur�C la Phone��8 z�'] "/ _ ._ Owner's Name �� swot ��sc , Contractor /YJ�gN•6EK4EN1 Address LUu, Jl k f07 5•S• 454-iicense No. �Phonegr'� 2Z7- spa' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ QpBR/zJ GS PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERX (✓ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing _ ❑ Oen Bottom ❑ Manteca Dia. of Well Excavation _ ❑ Industrial P Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Type of Grout I'l Public (-AOtherf-1 Delta Depth of Grout Seal 11 Irrigation —Approx. Depth I 1 Eastern Surface Saul Installed by O%/ - ;;;. ,a Repair Work Done 11 Type of Pump H P State Work Done 017 Well -- Destruction ❑ Well Diameter Sealing Material (top 501 —�-�-/ Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION DESTRUCTION I availabPerwithin 200 fee itlad it public sewer is 1 Installation will serve: Residence— Commercial_ Other Number of living units: _ Number of bedrooms Water table depth -- Character of soil to a depth of 3 feet: . Capacity No. Compartments SEPTIC TANK Ll Type/Mfg --- Method of Disposal - PKG. TREATMENT PLT. ❑ ' Distance to nearest: Well Foundation Property Line — i - LEACHING LINE ❑ No. & Length of lines Total length/size ---- FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Siza Number SUMPS L7 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 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 thi ermn is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's sub-contracting signature certifies the follow ."I certify that in the performance of the work for which this permit is issued, I shall employ perO to workman's compans'a- tion laws of C oral .' The app)' tcall f fired 11L.—W;)omplete drawing on r side. — Signed X 1 Title: FOR DEPARTMENT USE ONLY �2Q Date � -7 Area Application Accepted by ___.._r=Y 0-9 Date Final Inspection by Date Pit or Grout Inspection by q Additional Comments: �- o. --tJ/G►�+•'- All c�i.�...� L.vr ,p��B .� � Lyr..eQL u/Ls•-�.:..-E/ 11Sik 466-6781 11 Lodi 369- 1 ❑ Manteca 823-7104 ❑ TracY 835-�J05 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK RECEIVED BY GATE PERMIT NO. AMOUNT DUE AMOUNT REMITTED INFO CASH x EH 125IREV.1/x51 EH 1440