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9+ 6a;�%Cr,,3`F¢':+�':aM•,,rMHi, �-may„"- . APPLICATION FOR PERMIT #� 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) i Application is hereby made to the San Joaquin Locat 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 City C Lot Size 5 P nCM 1 y Owner's Name r Address Phone Contractor Cry c Address I 1_0 License.No, d�� i�� Phone TYPE OF WELL/PUMP: NEW WELL: 0 WELL REPLACEMENT ❑ DESTRUCTION O PUMP INSTALLATION ❑ .. SYSTEM REPAIR U. OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER EINES _ DISPOSAL FLD. PROP. LINE FOUNDATION,' AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE:- TYPE OF WELL 4PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial.?" ❑ Open Bottom '❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/$rivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I ['1 Public - ❑ Other , 171Delta Depth of Grout Seal Type of Grout I I Inigalion ..,Approx. Depth i l I Eastern Surface Seal Installed by Repair Work Done" ❑ t e of Pum I H.P. _ YP P State Work Done Well Destruction ❑ Weil Diameter Sealing Material hop 501 t Depth� P I �' . Filler Material (Below 501 C � TYPE OF SEPTIC WORK: NEW INSTALLATION'I REPAIR/ADDITION I I DESTPUCTION I I INo,septic system permitted if public'sewer is j t I available within 200 feet.} i Installation will serve: R sidence '—Commercial Other Number of Erving units: � Number of bedrooms T . Character of soil to a depth of 3 feet: I� M — Water table depth SEPTIC TANK fy Type/M( ; '! 9 Capacity-16(10' ._ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal . / t Distance to nearest. WeN 19zo Foundation Property Line 130 LEACHING LINE L`f--No. & Length of lines -3 Total length/size 3 I FILTER BED, F;�- Distance to nearest: Well I Foundation "( Property Line _75 # I. 1�0 i i SEEPAGE PITS I't` Depth Size *, Number' SUMPS Cl Distance to nearest: Well / .s } Foundation:per r' Property Line { DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in.actordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health D11trict. 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,)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." I The applicant must call far all r wired inspections. Complete drawing on reverse side. . Signed'X �. Title: Mt, Date: . . t 4 " FOR DEPARTMENT USE ONLY ( �/ Application Accepted by Date ✓�� =4�i Area Pit /� II Dae Final Inspection byriGrout Inspection ct on bY dditonal Comments: i_ I ❑ Stk 466.6781 ❑.Lodi 369-3621 C3 Manteca 823-7104 ❑ Tracy 835-6385 ' Applicant- Return all capias to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 - FEE AMOUNT DUE I AMOUNT REMIT-TED CK INFO CASH RECEIVED BY DATE PERMIT NO. � 1 +.EH I3-24{REV.I i H 51 /y '--•- � EH 14 L / �� ! .11� �8 /t�4�►I - � r_'-CJ\Ae�I - ,�.,,,,„..,,,' �10L �.+W�T.r�-we-�•�: � rf-70],-�ti .�