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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 tot :;q _.=-'LaZF"I' L .::.,.' :r :;.. _ (Complete in Triplicate) Application is hereby merle to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is 1 made incompliance with San Joaquin County Ordinance No:599 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Heahh D-rstrict.s,.,,,SM,.` ">^ i:� ^•,. _.Ql:."ArJ ':: '°.1L" ?1+W ir+ _/ �,(+LG...� _� � �}��d lit: • ]: �'� J 'J _ Job Address �/ �• E/�• .`+w qty v_____/J`.--'''— Lot Size � •7. - PM Owner's Name fY[ � — "/" t�i,�/iAddless az'e 'L Phwne �•��` CdttQ ort s Name J[,k.CC' �_� License No. �� 9 Phone G �d(' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ ' DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C OTHER C - DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS r Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C Domestic/Private ❑ Gravel Packk C Tracy Type of Casing Specrficiiu n ❑ Public C Other 4 r ❑ Deha - Depth of Grout Seal - Type of Grout 0 C Irrigation ---Approx. Depth ^❑fEastem Surface Seat Installed by Repair`Work Done El Type of Pump H.P. � , State Work Done Well Desfluction C Diameter Oiaeter Sealing Material ft Depth ' Filler Material (Below 60'; �"- -- -- TYPE OF SEPTIC'WORK: NEW INSTALLATION? REPAIR/ADDITION❑ DESTRUCTION ❑ (No septic system permitted H publiC'Sewer a >, available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of Irving units: Number of bedrooms 5 —Character of of soil to a depth of 3 feet: D 6 q Water table depth G _ SEPTIC TANK ❑ Type/Mfg__. _ ' Capacity_ No. Compartments , l-,PKG. TREATMENT PLT. C " . -'Method of Disposal Distance to nearest; Well rFooundation -—ZPropertyLine ' LEACHING LINE No. & Length of lines �7 V Total length/size FILTER BED CDistance to nearest: Well Foundation Property Line r _ SEEPAGE PITS ❑• Depth; r Size _ - f9umber SUMPS X Distance to nearest: Wella-D Foundation �D Property Line DISPOSAL PONDS -1 I hereby certify that I have Prepared this application and that the work will be,Eone in accordance with San Joaquin county ordinances,state laws, and rules and regulations of the San Joaquin Locai Health:Dls:rict. Home owner a licensed agents signature cartifies.the following: "1 certify that in the performance of the work for which thisPermitis 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 subcontracting signature carphas 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 Cali a." I - t ti The applicant- w call for I require inspections. Complete drawing on re/v$/��adys/.,�//� Signed `•�� Title. in/ti"+•'T Date: -,rte FOR DEPARTMENT USE ONLY { ��L•�, 'Application Accepted by ` Date (�Y �—t�yA�rea (S;:8rout Inspection by �e---tt+%�. ,..-late�3` //�� _F�ina�l Inspection by CY �- '�•^ - Date Additional Comments: �� `z L' `6 �^""^� -" 4;?Ij C Stk 466-Ml O Lodi -369-3621 ❑ Manteca 823-7104 ❑ Tracy Applicant- Return all copies to: Ewronmental H"Ith Pem,h/Services 1601 E. Hazehon Ave., P.O. Box 2009, Stk., CA 962ol - FEE -' AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMfYNO. FO IN araailREv.tpres ' ? -(, 1511 Er,aa