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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 (Complete in Triplicate) ' Application is hereby made to the San Joaquin Local Health District for a permit to construct and;or install the vork herein described.This application is I made in compliance w th San Joaquin County Ordinance No.549 for sewage or No.1862 for well/pump and the 1.4les and Regulations of the San Joaquin Local Health District. M �� 1 lah�,G�ot Size_ PM - Job Address ) °=— contractor - City J1oil 5•cu �? PhoneOwner's NameJ��-z--�-"��t'P.r Address _ License No. __Pi,one TYPE OF WELL;PUMP: NEW WELL LJWELL.R'-PLAC cMENT C DESTRUCTION U PUMP INSTALLATION Z. SYSTEM REPAIR u OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES .- DISPOSAL FLD. PROP. LINE -- FOUNDATION _ AGRICULTURE WELL OTHER WELL - PITS/SUMPS _ INTENDED TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia.of We:1 Casing C Industrial 2 Open Bottom -, Manteca Dia. of Weli Excavation_ Specifications G Domestic/Private O Pack Tracy C Public [I Other Type of Casing Other Delta Depth of Grout Seal _ Type of Grout.- C Irrigation -Approx. Depth Eastern .Surface Seal Installed by.__--- Repair Work Done E Type of Pump _-- H o._ State Work Done well Destruction r- Well Diameter _----.- Sealing Material(top 50'1 - Depth _ Filler Material (Below 50'1 - TYPE OF SEPTIC WORK: NEW INSTALLATION i REPAIR/ADDITI11111171711 O DESTRUCTION availableseptic wthin 20stem 0 feet.) if public sewer is Installation will serve: Residence 1-<' Commerciali:11--- Character Other.._. V Number of living units: Number of bedroon - -Water:able depthisk _ Tr of soil to a depth of 3 feet:-G � f --- - Capacity No. Compartments SEPTIC TANK Type/Mfg y�Cl� -►7I ---- --- rl Method of Disposal PKG.TREATMENT PLT._ - }1 D,;taw:e to nearest: Well -_-. Foundation_-- Property Line / Total length:size--- LEACHING ize- -LEACHING LINE = No.6 Length of tines - ,/ � Foundation_ Property Line_ FILTER BED X Distance to nearest: Well��--- /-'Depth _-Size Number SEEPAGE PITS - Foundation--- Property Line SUMPS Distance to nearest: W-111 -- 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,an. rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:"I certify that in the wrformance of the work for which this permit is issuedrig ,I shall not tion s of cert employ sthe following:person rin such"I certify that intheperfo mance of the wok forr which thbecome subject to workman's is permit is issued,I shall emplay personsornia."contractor's rsubjeet to workman'ring or s cc signature 9pense- - tion taws of California." The applicant m"41, nu •call for all ed in coons. Complete drawing on reverse side. �71}/�/J� Title- Signed X - Date: \ FOR DEPARTMENT USE ONLY Date_ Area Application Accepted by �— A `� r Date. _.___-_ Final Inspv\ion by_ _ 3 cr,t _ DatePit or Grout Inspection b r �P 5�n Gf�t �^Additional Comments' Tracy 83rr6385 0 (,� !/� C O�l`�' `t� by (6 - Lodi 466 6781 Lodi1 = Manteca fi'3 7104 2009 C / Z Slicant- Return all copies to: Environmental Health Permitr'Services 1601 E. Hazelton Ave., P.O. Box Stk., A 95201 . CK- FECEIVED BY DATE PERMIT NO. INE AMOUNT DUE _ AMC_NT RE!.�iT-IED t_ CAS _,---__ `361 8 EN!3.4,REV 14?1 t- F