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' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466.6781 t PERMIT EXPIRES 1'YEAR FROM DATE ISSUED •I (Complete in Triplicate} t an /or instal the work here ' Applicaon is mado nticomplcation is l'Itaence with made San Joaquin County ordinance No.54'3 for sewage oriNo.1862 for alth District for a permt to cwe I/dpump andl the Rules and IR described.gulations of the Sant Joaquin Local Health District. 1,i /y t PM 4/ 7 ff' / '`w rC city_- Lot size t Jori Address Address Prone Owner's Name -e,:;<, , - ,:: t .u.. .. Contractor' d License Nos�ZF�c1� one ' Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 11SYSTEM REPAIR ❑ OTHER C3 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' AGRICULTURE WELL OTHER WELL PITS/SUMPS . FOUNDATION INTENDED USE, 1.' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia.of Well Casing ❑ industrial "_❑Open Bottom ❑ Manteca Dia.of Well Excavation Specifications ❑Domestic/Private ❑ Griii Pack ❑Tracy Type of Casings-�-- ' 19 public 11 ❑ Delta Depth of Grout Seal Type of Grout_ - ❑Other * y 1, ,Apprax. Depth I 1 Eastern Surface Seal Installed by I I Irrigation State Work Done'_ r Repair Work Done` ❑ Type of Pump H.P. r Sealin Material(top 501 ' ' Well Destruction F� ❑ Dell•Diameter - 9 S Depth Filler Material(Below 51 I TYPE OF SEPTIC WORK: NEW (NST'LLATION U REPAIR/AODITION DESTRUC�TIIOONNII I aNailseptic Wtem thin 2r'pefeet rmitted if public sewer is ' Installation will serve: Residence Commercial_ Other �'��+� 5/Or✓J'� Number of living units:_ Number of bedrooms �„ I( Wader[abledepth 'Character of soil to a depth of 3 feet' 1?L� Capacity '- 1. � _,-No.•Cbmpartments SEPTIC TANK ❑ Type/Mfg ! Method of Disposal PKG. TREATMENT PLT.❑ ri /G1 /ST Distance to nearest: Well_.— Foundation Property Line •T — / y Total.lengmisize X0.0 rI ' LEACHING LINE No. B Length of lines —,_ f. �Tpro a Ling FILTER BED ❑ Distance to nearest: Well, ,Foundation — P M -+-�---- tIl SEEPAGE PITS I l Depth - Size Number SUMPS - f_1 Distanso-to_nearest: Well Foundation Property Line_-- ' I DISPOSAL PONOS ❑ � - I hereby certify that 1 have prepared this application and that the work will be done in accordance with Sen Joaquin county ordinances,state laws, and rules and regulations of he San Joaquin Local Health D3vict. w ' Home owner or licensed agent's signaiure certifies the following: "I certify,that 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:"l 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." • . r ,^. ` The applicant must"It f�orfy,_,�/requuad specJti Complete drawing on reverse side.'*' Yi�ir�rr `.... Signed X A / Title: --Data: rI // / //�////FSR UEPARTMENT USE ONLY /��C{//�P IYAAA w Date Area ' Application Accepted by a : _ Date - Final Inspection by t?cd� Date 3 �6 Pit or Grout Inspection by .- C' I Additional Comments: ' ❑S[k 46"781 `� O Lodi 369-3621 ❑ Manteca 82&7104 ❑Tracy 835-0305 Applicant- Return 811 copies to: Envir 6nmental Health Permit/Servieas 1601 E. Hazelton Ave., P.O. Box 4009, Stk., CA 98201 . CK . ..RECEIVED-By•-_• DATE'^- " '-PERMIT NO. '.+•"~ FEE . ayon -0UE. • AMDUNT-REMI—:T TED -CASH _v_ INFO- -.�.- -.r. _ ' I i.Ea l3N iaEY.I/n51 7�_ �� O. W �� ou,3-w