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A / A APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 486 6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the Sen 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.569 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. q ' Job Address CJ city Lot Size IXe 'odeew-4 PM Owner's Name Address -- �?'np } Phone -96 ConSacioJe.Name .1t License No. -J-.S ( -Z�i Phone TYPE AF WELL/PUMP:, . �:,NEW WELL ❑ r WELL REPLACEMENT ❑ � DESTRUCTION O - CErA, STALLATION ❑ ) SYSTEM,REPAIMO1O�HER ❑ TANK SEPiIG , SEWER LINES DISPOSAL FLD. PROP. LINE its G i it EM\ dh l FOUNDATION AGRICULTURE WELL OTHER WELL—.PITS/SUMPS \ H El(`"VNTENOED U§EI41 I,TYPE OF WELL PROBLEM AREA 'CONSTRUCTION-SPECIFICATIONS---- 0 Industrial•>-i+A C•Oplerf ttotri ,�❑ Manteca: , Die. of Well Excavatirin'iA Die. of Well Casing > a% _ ❑ Domestic/Private Or.G-ravel Paul. (.+❑ Tracy Type-of Casingr . t Specifications ' ElPublic_. ❑ Other to 11Delta - Depth of Gro 11 are Type of Grout ❑ Irrigation ---Approx. Depth❑ Eastern- l -SurfaeeSa51"Inatn W) V s Repair Work Done ❑ Type of Pump N.P. I - 1 ' State Work Done Well Destruction ❑ Well Diameter "1'r~• - SBeling Material (top WI t i A Depth Filler Material(Below 50') it TYPE OF SEPTIC WORK: NEW INSTALLATION ''REPAIR/ADDITION ❑ DESTRUCTION O (No septic system permitted"rf public sewer is "^I aJailable within 200 feet.) W Installationwill serve: Residence Commercial Other t ,dumber of living units: --/- NumDer of b�rs _ - Character of soil to a depth of 3 feet: � � '� Water,table,depth 1 • SEPTIC TANK O Type/Mfg Capacity tJVNo. Compartments Z� ^�- PKG. TREATMENT PLT.❑ Iyt ' '"' -"�`—lf Method:ofuDisposal � Distance to nearest: Well�.LL L Foundation ��:}i Property Lined -..�', 2 e � '•y � LEACHING LINE No. 6 Length of lines• : I ' .4 , bngI size �a 1 FILTER BED El Dlstanca to nearest�""i Well'r SQ 'f Foundltio '`Property Line f L� i SEEPAGE PITSh � Sias __3� I \ v- Dept �- Numbx SUMPS - ❑ Distance to nearest: Well 160 Foundation AP °' Property Line' S , _O .. DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance wi)FI San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or lioensed agents signature certifies the following: "I certify that in the performance of th\ork for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation tam of California."Contractors 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- don laws of California." The applicant must call fpr all re�ei,r�d in�s� ' a. Complete-drawing on reverse side. _ i ' / L�.tl(i _ . `y/ mss' Signed x , fele: � r ' Ddte_: �J FOR DEPARTM USE ONLY r 1 1 � Application Accepted by - //G yJgni Date /r.- A j G V or Grout Inspection by ��/�/,1 Date Final Inspection by Dgts lAldditional Comments: ❑ Stk 466-8781---0 Lodi-3tl=3827_--t]..Manteca-1l237107---^S-T- ey._8954M — ---.- _ Applicant - Return all copies to: Environmental Health PermWServices 1601.E, Ha Icon Ave., P.O. Box 2009, Stk., CA 952D1 FEE INFO AMOUNT DUE ' AMOUNT REMITTED CASH `RECEIVED eY ♦y'DATE PERMIYTID. . Ell 1}24(MEN teleil EH 1426