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. _ >,:.R.Y�.�..�..,a•,..,...,Kr...><-,;.._-w.,....,,<:rm„^�ea....swnx.m.-n.tezA �le� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT *�W 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209)466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplirate) Application is hereby made to the San Joaquin Local Health District for a permit to constnlct anti/or install the work Iask dsserbrd.Thla.ppYeaUon made in compliance with San Joaquin County Ordinance Na.569 for sewage or No.7867 for well/pump a.,d the Rubs and Regulations of the San Local Health District. Job Addrpsc p !/�/ Citt-SCALOIJ Lot Si:. _vM G r Address 3 I a S FYF.Ano IC4 t _ Phone !' 5 Owner's flame . Contractor / sr, W A Lit AL Address 3"D VJ C ) �(�License No._!4230 -Phone p TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL ___OTHER WELL PRS/SUMPS w INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑Open Bottom ❑Manteca Dia.of Well Escavation DIs.of Wag Casing ❑ Domestic/Private ❑ Graven Pack ❑Tracy Type of Casing Specifications K4) O Public ❑Other ❑ Delta Depth o1 Grout Seal Type of Grout ) 11) ❑Irrigation ---Approx. Depth ❑ Eastern Surface Seal lnstaded by Repair Work Done ❑ Typo of Pump H.P. Sate Work Done _ Well Destruction ❑ Well Diameter Sealing Material(top S09 Depth Filler Material(Beruw Iam) _ TYPE OF SEPTIC WORK: NEW INSTALLATION CyiREPAI R/ADDITION ❑ DESTRUCTION O (No septic system permitted B public sewn 5 I' Installation will servo. Residence O�Commercial_ Other available within 20D feet.) Number of Ening units:-I— Number of bedrooms.�_ Character of soil to a depth of 3 fent L 00,Ny" Water table depth \ SEPTIC TANK L4--lype/M1g l O r Y��-�_ Capacity 11L•� No. Compartments PKG. TREATMENT PLT.❑ y•/y� .. Method of Disposal T Distance to nearest: WNIJC/ Foundation Property Lire_rte i l i LEACHING LINE 0_,Ko.8 Length of lines -� � �'B Total length/size_._ - __ � FILTER BED ❑ Distance to nearest Well -? 7{7 /0 Foundation . ('1 Property Line '�sa SEEPAGE PITS ❑ Depth N _Size__ Number '--3 SUMPS ><Distance to nearest: Well ,_ Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that ti,e work will be done il.accordance with San Joaquin county ordinances,state rows,and n{es end regulations of the San Joaquin Local Health District. Home owner or hcensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued.I shell not .^Iby any Person in such manner as to become subject to workman's compensation laws of California:'Cu,-tractor s hiring or sub-contracting signature he following:"!. ertify that in the performance of the work for vfiich this permit is issued,I shall employ persons subject to workman s compensa- Cali•ornis.' :an s! all for req e0 in ct n . �1�7npima\)tlswing or se sidy/T— '� - (d'/O L Date:�� FO ARTMENT USE ONLY �y Application Acccoted by ` CSS� Date Am Pit or Grout Inspect y f_t1L( _ Dab Final Inspection by z f kms'_ Data Ltd Additional Comments: _ C Stk 666.6781 ❑Lodi 369-3621 C Manteca 823-7130 ❑Tracy 3155335 Applicant- Returc all copies to: Environmental Health Permit/Services 7601 E. Hazelton Ave., n.0. Box 2009,Stk., CA 95201 INfO AMOVNT DUE A1607NT 5EM'R1TEO _CASH RECEIVED BY DATE Of yPrERMIT'N0. y., EN13NMEN` .. .-n�- -�Q' OcJ IoGlz IVn j2_3-11P ,;'t��7S8y EN1.2% s� _