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APPLICATION rOR PERMIT p SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON• CA Telephone (209!466.578. PERMIT EXPIRES ! YEAR MOM DATE ISSUED (Complete in Triplicate) AWcaliun is hereby made to the San Joaqu;n Local Health District for a Permit to constwct andlor install the work herein described,This application is made in compliance will,&v,Joaquin County Ordinance No.549 for sewage or No.1862 for well/pump and Ilia Rules and Regulations of the San Joaquin - Local Health Orsuicr. �y Job address �9w-_ Lot Sire PM . ownet's Name '' Address -•ty Phone �'rcrwsr� `tcfS�r`3 l/�{f� Contractor Address License No.-4&43-2�'f—Phone TYPE OF WELLlPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCT)("I ❑ 4.r.-t( P!fMP INSTALLATION Q SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST; SEPTIC TANK I SEWER LINES DISPOSAL FLO. PROPr LINE " FOUNDATION —S f AGRtCULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCftON SPECIFICATIONS {; Q Industrial ❑Qpen Bottum ❑Manteca Dia.of Well Excavation pia,of Well Casing FI DomesticlPrwair. ❑Grave!Pack ❑Tracy Type of Casing Specifications 1'i Public I'i Orher FI Dells Depth of Grout Seal Typo of Grout - I t lrrigalinrt �,�[�+JApprox, Depth I I Eastern Surface Sedl Mslalled by - Repait Work Done 13 Type of Pump H.P. State Work Done� — Well Destructiort 1,! Well orameter - Swaling Material(top 50'1 Depth Filler Material tt3e;C:r.501 -- - ' TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION t I DESTRUCTION I I lNo septic system permitted if public sewer is available within 2(16 feet.) Installation wilt serve: Residence_ Commercial_ Other Number a.fiving units: Number of bedrooms -•�'" �- r, Character of soil to a depth of 3 feet: Water table depth_ _ SEPTIC TANK C1 TYPelMt9 _ Capacity No.Compartments PKG.TREATMENT PLT.Fl Method of Disposal Distance to nearest: Well Foundation Property Line - - " LEACHING LINE Ll No.&Length of fines�, Total lengthlsiie - FILTER BED ❑ Distance to nearest: Wet Foundation Property Line _ SEEPAGE PITS I 1 Depth Size_ Number t( SUMPS I I Distance to nearest: Wert Foundation Property Lino = DISPOSAL PONDS Fl --- 1 hereby certify that I have prepared this appkation and that the work will be done in accordance with Sar,Joaquir,cduniy ordinances,state laws,and - - ruias and regulations of the San Joaquin Local Health District, Home owner or licensed agent's signature certifies the following:"I certify that in the porlormance a'the work for which this permit is issued,1 shall not - -_ employ any person in such manner as to become subject to workman's Cumpensati�n taws of California."Contractor's hiring or sub.contracti;+g signature - certifies the totlowing:"I certify that in the performance of the work for which this paratir is issued,I shall employ persons subject to workmans eompensa• - lion taws of Cahlomia." The applicant must cap for aft fwtuirad inspections.Complete urawing en reverse side, Signed X Titfe• Date: _ FOR OEPARTk ANT USE ONLY Application Accepted by ; ir�.�,e Y—� — _ Data ` 'T� h / Area Pit or trout Inspection by 'Data- Final inspection by. - Date rad - 'Additional - f_1 Stk 406 6781 0 Lodi 369-3621, O Manteca EL23-7104 L7 Tracy 835(,385 Applicant:,`Return all copies to:Environmental Health Permit/Services 1601 E. Harelwo Avn.• P.U.Do.2OD9, Stk.,CA 95265 - r-CE AMOUNT DUE AMOUNT REM17TE0 CKs - H!C[tvC17 RY OATC PERMIT NO. - rNFO CASH - CH 91-24 10tv 35 + t �