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APPLICATION FOR PERMIT 718 dd�j SAN JOAQUIN LOCAL HEALTH DISTRICT fI 1601 E\�HA`ZEL4i3O�l\kVE:, STOCKTON, CA Telephone (2091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Q88 Application is hereby made to the San 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.549 for sewage or No. 1862 for well/pump and the Rules andPi3gg1@tq;rotr �a�yir� Local Health District. 1,t k r EWAI /SERVICES, Job Address 4� YV< • •v r-'IA1�t/YY Jar! 4y�ize PM Owner's NamAddress t?o +, 0J Contractor Address A 1789C ly 7, License No.1hina-Phone TYPE OF WELL/PUMP: N W WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ V PIP INSTALLATION � SYSTEM REPAIR ❑ OTHER ❑ �Y DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FUD. PROP. LINE y FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS y %% y; INTENDEDIJSE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ✓i/" 1 ndustrial Y•L ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications j I 1. t F1 Public fl Other 71 Delta - Depth of Grout Said Type of Grout_ i Irrigation _y.Approx. Depth I Eastern Surface 1 Installed by _ Repair Work Done ❑ Type of Pump �� H.P. State Work Done Ji pp Well Destruction ❑ Wd1 Diameter Sealing Material (top 501 ,/ ' Depth Filler Material i8elow 50') t TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is • � available within 200 feet.l ' Installation will serve: Residence— Commercial_ Other ! 4 Number of living units: Number of bedrooms I Character of soil to a depthof 3 fast: Water table depth ; SEPTIC TANK \QN❑`illypelMfg.t. \t, Capacity No. Compartments I f"PKG. TREATMENTLVLT-h. yy .�.__-_•-� _..Y- -.-------- �, Method-of-Dispose. F �. lNstance to nearest: Well Foundation Pro 5 � _ party Line f LEACHING LINE ❑ o. 8 Length of lines I I ,.1_� I Total length/size rt FILTER BED ❑ istanca to nearest: Wali ...-+t +r _�_ Found'ation Property Line 7 SEEPAGE PITS - l I epth Size Number SUMPS ❑ ' istance to nearest: Well _ Foundation Property Lina 1 DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws and j rules and regulations of the San Joaquin Local Health District. _ I Home owner or 1' is signature certifies the following: "I certify that in the performance of the work for which this permit is issued.I shall not employ; n in such r W to become subject to en's m nsation laws of California."Contractors hiring or subcontraotin i signature certifies the E9 'ng:"I certify [i the perfA w k for ch ths r it is'asued,I shall employ perwns whjac[to workman's compensa- tion lawsCalifornia."The eppli nt must II for r fired ins ce n on r ,< Signed X Date: FO RTMENT USE ONLY j Application Accepted by 1 DateArea Pit or Grout Inspection by I� Date Final Inspection by---J2� Date l ,j Additional Comments: pl O Stk 4666781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE I� i NFO AMOUNT DUE AMOUNT REMITTED71 CASH RECEIVED BY �iDATE�y. PERMITNO. A 12211REV.,/.sI EH 14� OO 00 I