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r APPLICATION FOR PERMIT �7 SAN JOAQUIN LOCAL HEALTH DISTRICT i q 1 1601 E. HAZELTON AVE., STOCKTON, CA � p Telephone (209) 466-6781 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (Complete in Triplicate) 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. Job Address -3 (,- ,3 / ` Cityixia Lot Size Z C+K/(.��.• PM 141. A. 6 3 -i� 6' Owner's Name ' ✓, ddress � � � _ Phone 51 X22 Contractor) "Address � License No. Phone TYPE OF WELL/PUMP: NEW WELL LJ REPLACEMENT ❑ DESTRUCTION El �I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications " I 1-1 Public Cl Other F1Delta Depth of Grout Seal Type of Grout 4 11 Irrigation —.Approx. Depth I i Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done �1 Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth er terial {Below 50') ' TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/AD ITION i,I DESTRUCTION INo septic system permitted if public sewer is r available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth f f SEPTIC TANK ❑ Type/Mfg Capacity./Z 0 ® No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal ' Distance to nearest: Well., Q— Foundation ® Property Line LEACHING LINE ❑ No. & Length of lines Total length/size , FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth. c Size "� Number e { SUMPS Ll :Distance to neares Well [^f Foundation f rte_ 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 this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's 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." 111 111 The applican ust call for I requir d inspections. Complete drawing on reverse side. Signed X Title: Da / te: F11 FO DEPARTMENT USE ONLY Application Accepted by Date Area 0 If Pit or Grout Inspection by Date Final Inspection by Date f Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3M4621 ❑ anteca 823-7104 41 Tracy B35-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r� �4 .-�- -.... p -. A- -� ax• '. ..�, ry1-� �M.aryg�p ry v.5.-e .ga�¢ q��r t"r"sre�--°6hY 4y ��!�T 4 T. t . - �� t �i�YS�t Yak':{f i� ti�i.�. fR3�..1'$XL ".Flu( r�r�L+rxr'-'E.: ��r} �N� 5�S Y ren'��3 C:3 Ib�..tPi�NI��S��4��'.-I oFV�,,i}�xJ nJGa'!" �n'.G:'u4� 5�'Y4' r1•ZyJ"y� �� ! fl. I �; ��F! r x>: �y ,� _ i �Y�l-1 0 �..�..✓/,�.»... �...y = h -w..'�...�n.a«.: e=:>::� q �. �x;.s.�.��v'�.+.-.�.r-l{�^+j..+•.-..-a�'.'mc�y.:m.��r� c-r�.x t 1 x. + r:r1.Tt.LLr ., .. ; � .� "�'' ..' `� � ' �r ' �. E- ,.rr�,.-..-rx'+'as+..+,._•e+:�--rte. -.•r'C ..--�,ee-¢.. lP�'i., .�. r.,gtf..?Ik.tlse y r..`K'