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APPLICATION FOR PERMI- ' SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE T ON AVE., STOCKTON, CA 2 hine Tele G ( 03) 466-67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (COmplete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described, made in compharca with San Joaquin County Ordinance No.549 for sewage or No. 7B62 for welfl um and the RU!as and R This application n Local Heahh District- ! p P egufaiions of the San Joaquin S z Job Address Z�C lot Sir PM Owner's Name 1 J 3 4 x 7 3 ddress 1' Phone Contractort��,�� Sa m_Address�r RL n r 590�� 3 ' +'YPE Oi WELLIPUMP: NEW WELL ❑ tense No_ Phone WELL REPLACEMENT 0 DESTRUCTION q I _ PUMP INSTALLATION p SYSTEM REPAIR C7 DISTANCE TO NEAREST: SEPTIC TANK OTHER 0 F SEWFR UNU', DISPOSAL FLD.�t-UNpATION AGRICULTURE WZ!L PROP, LINE ' g INTENDED USE TYPE OF WELL PROBLEM AREA C OTHER WELL PITS/SUMPS } CI lndustral ONSTRUC1ipN SPECIFICATIONS C7 Open Bottom la Manteca f7 Domesti^1Privase Dia. of Well Excavat ---- r ion Dia.of Well Casi ublic nng C]0 Grave!Pack ❑Trac f'I Py Type of Casing \ Other Delta Depth of,rout Seal Specifications Irrigation __—Approx. Depth I I EasturnType of Grout 7 Repair Work Prone U Type of Pump Surface Seal Installed by a — i H.P. -- State Work Done i Well Destruction !� Well Diameter i — Seating Materia!Stop`,0'1 Depth Filler Materitf!Below 50'I `v x � TYPt OF SEPTIC WOAK: NEW INSTALLATION I 1 REPAIAIA.ppITID �f QESTRUC7ION I 1 INo septic system permitted if public sewer Is 4. Installation will serve: Residence_ available within 200 feet 1 C Commercial_ Other - \• .�if Number of living units: �kli'Si/ r,; ow f 7., g Numhor of bedrooms � Character of soil to a depth of 3 feet: 1 SEPTIC TANK 171 Type/Mfg Water table depth�`� ; .r , TREATMENT ALT.Cl p Capacity_ No.Compartments i• ,.:SFw4'4 '�arest:,,� r � � Method of Disposof Distance to nearest: Well ��_ oundation_le Property Lino' 5�c 6Ye�vsrp ri t�d►� (>. , LEACHING LINE ID No . & Length of lines �+ I• FILTER BEDf-:1 Distance to nearest: Well -- rOfal length/sire ' __ Foundation Property Lina F4a SEEPAGE PITS I I Depth k -.._Size II SUMPS 11 Distance to nearest: Well -- Numbsr DISPOSAL Pf1ND5 -1 Fourdation Property Line?� 1y` I hereby certify that I have prepared this application and that the work will be cone in accordance witty San Joaquin county ordinances,state taws, and 1 rules and regulations of the Sart Joaquin Local Health District. i. Horne owner or licensed agent's signature certifies.i:?following: "f certify that in the performance of the work for which this permit i9 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 Certifies the following:"t Certify that in the performance of the work for which it vs permit is issued,f shall employ parsons subject to workman's com tion laws of California," " The applican st call fora egair�ins ranse. /� ` pections, Complete drawing on revsrse side. • r., 1i14- �C. - Signed 7( v Title: L6L, (� Date: FOR DEP FITMENT USE ONLY 7 Application Accepted oy J —� DateQ Are. Pit or Groul fnea sp6ction by ` ' — Date final Inspection by� AGditio:tal Comments: to{ ' (J Stk 466.6781 7 Lodi 369'3621 ❑ Manteca 823.7164 E3 Tfacy APFiicam Return all copies to: Environmental Health Permit/Services 1601 EHeselron A3 e6385P•0, Box 2009 Stk., CA 9WQ1 FEE AMOUNT DUE INFO AMOUNT REMiTTEC CK s t3{CErvCD BY �„ - —_ CASH DATE PERMIT' . EH t3.4Ipty.",, , - 0 - (//�+(/ (/r}L fI/y} NO.� EH 14 .M /L� ` U. 2n- 4i ', !V lj'/; A n,- Y 1�r I