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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E- HAZELTVN AVE., STOCKTON, CA Telephone 12091 466.6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - --- (Complete in Triplicate) nl,n•r.Km n hereby made ro the San Joaquin Local Health Drstmt for a PORN to constrict and/or nets/It's work herrn described This application is Tndw,n crrnpaance wnh San Joaquin County Ordinance No 549 for sewage or No 18!12 for well pump and the Rules and Regulations of the San Joaquin all Hlerh D'VnCi �^ ) /1 r / �f 1:•n Adducts _u/�� !�I`INC- City�tR'tti_ Lot Sian- - PM 't Addres /V n C�,,I�e r � • /3/a/1/ 6,*RrcenseNo. �jLL��Phok TYPE OF WELL,PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION U PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK -_-- SEWER LINES _ DISPOSAL FLD. PROP•UNE FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUWS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS_ Industrial �' Open Bottom ❑Mordecai Dia. of Was Excavation Dia of Woo Casing Domestic/Private C: Gravel Pack C Tracy Type of Casing SPOCACat""' Public Other C Deka Depth of Grout Seat Type of Grout'rogation _Approx. Depth ^ Easier Surface Seal Installed by ---- (� Repair Work Done Type of Pump __ H.P. State Work Done Well Destruction Well Diameter _ See"Material(top 50'1 \ Depth _ Fier MstwiM(Below 50'1 - TYPE OF SEPTIC WORK: NEW INSTALLATIONVA" REPAIR/ADDITION Ll DESTRUCTION (No esprit system P"Inlit if Pubic sawaE s aved"within 200 fest-) Installation will serve: Residence IX Commercial_- Other Number of living units:_Z___ Number of bedrooms_ Character of soil to a depth of 3 feet: _ _ y-�_Water table depth -__-- SEPTIC TANK �^Type/Mfg _.�Q1 - Capackyi��y /NO Compartments __2 ------- PKG. TREATMENT PLT. --' Method of Disposal _-- Distance to nearest: Wen -�Foundation_l _ Property Line LEACHING LINE No. 6 Length of lines __------- Total ktngth/size FILTER BED - Distance to nearest: Well Foundation - __ —_ Property Lina_-- SEEPAGE PITS ❑ Depth _-- Size--- -- Number - SUMPS C Distance to nearest: Well - _-- FoundAO-)n -_-- _---._- Property Line DISPOSAL PONDS C I henrby certify that I have prepared this application and tt,at the work wn be done in accordance with San Joaquin county ordinances,state laws, and rubs and regulations of the San Joaquin Local Health District. Home owner or(incensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall r.•rt employ any person in such manner as to become subject to wcxkman's compensation laws of Carrforia."Contractors hiring or sub-contracteq si n uns certifies the following:"I certify that in the performance of the work for which this permit is issued,I Shen employ persons subject to workmrn's compensa- tion laws of California... The a cant mu 11 for all re"I"" spections. Complete drawing on raven side. / le• - G'YX''r`-� — Date: �pa FOR DEPARTMENT USE ONLY _ 'J ---�` .G�� Date Application Accepted by Pit or Grout Inspection by ------- _ Date __-- _--- Finan Inapectbn by Additional Comments: — - Stk 488-6781 ❑Lodi 309-3821 ❑ Martteea M710E 1 Tracy 836-6M Applicant - Rmum all Copse to: EnvironmerltM HaMth Permit/Services 1801 E. Hazelton Ave., P.O. Box 2008, Stk., CA 96201 FEE AMOUNT DUE AMOUNT((EMITTED CASH ItECENED aY OATE P1 pMtT NO. INFO -F7. EH 11,24ieEv � + �/ 7, EM 1♦