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I _ APPLICATION FOR PERMIT. G SAN JOAQUIN LOCAL HEALTH DISTRICT • 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heleby 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. 1002 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. . I Job Address a�s~ V , City- -/2 a- Lot Size 7'O / —_ PM Lic A� Owner's Name .y� .ta�� Address �+',,G� Phone Contractor� � -� Address �1-�•rI _r 4469_U 1nse No. Phone 6��73j TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D 1 ( PUMP INSTALLATION.g.. SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ r I t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a {' U Industrial U Open Bottom ❑ Manteca Dia.of,Well Excavation Dia. of Well Casing ❑Domestic/Private ❑ Gravel Pack 0,Tracy Type of Casing Specifications I t1'(Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout_ kI I Irrgafion y —Approx. Depth 1 I Eastern Surface Soul Installed by I Repair Work Done ❑ Type of Pump H.P. State Work Done I I t. Well Destruction 't U Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50 TYPE OF SEPTIC WORK:- NEW INSTALLATION FM REPAIR/ADDITION I I DESTRUCTION I i INo septic system Permitted if public sewer is y available within 200 taet.l V Installation will serve: Residence ✓ Commercial_ Other Number of living units: t Number of bedrooms .Character of soil to a depth of 3 feet: Water table depth l t ISE IC TANK Uf�Type/Mfg G4 Capacity I(eQ6 No. Compartments `PKG. TREATMENT PLT.❑ CANE' r1 Method of Disposal f - Distance to nearest: Well L0 Foundation, Property Line LEACHING LINE LYNo. 6 Length of lines ^' •S 1 / Total length/size i t 510 FILTER BED D Distance to nearest: well CZ:_ FoUnalio� perty ProLine SEEPAGE PITS 141"Depth a S, �!^ size � Number SUMPS ❑ Distance to�near,esd Well © 1 Foundation1��01 Property Line DISPOSAL PONOS ❑ r I hbrebv certify that I have preparsd-this�application aNdNhat the work will.ba'done in,accordance with San Joaquin county.ordinances, state laws, and 1 rules and regulations of the San Joaqusif Local Health District. - Holme owner or licensed agent's signature certifies thaLf6114,Aq "I certify that.in the performance of the work for which this permit is issued, I shall not errify toy any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature cet4lfies the following:'9 certify that in the performance of the work for which this permit is issued,f shall employ persona subject to workman's compense- f do4t laws of Caliloinia." t �1 I I The applicant must calllf rO RIt r uired inspections. Complete drawing on reverse side. 1 ' �/� �f—� r�W Signed %__s5a�""" �,t1s:. Date: 7"` /, 1 �- i FOR DEPIARTMENT USE ONLY 7 S7� \AppliceCron Accepted by � ,'D,! Date Area !� �'� . I or Grout Inspection by `^' [ a s 4 incl Inspection by DatA!20 ((((VVAAdLitional Comments: ❑ tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835.6385 Apolicant- Return all copies to:.Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO T AMOUNT DUE 'AA�aUNT REMITTED CASH-1'• •sJ RECEIVED BY DATE PERMIT'NO. I 7tl �d, oOt � �f-7 for '�a i . EH 1124(REV. s) F EH 14M _ +ti