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ti APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 1 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 work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. u .,,, _110/1� Job Address 1 �'L.. City 010'1 Lot Size �G _- PM Owner's Name __ a'e_d ._ Address _�C'vj' L --- Phone A Contractor � � ddress + �� D� License No.�7s�._Phone _ _> - lam•--1r ` TYPE OF WELL/PUMP: _ NEW WELL P _ _ WELL'REPLACEMENT. ,7 DESTRUCTION_L _ - 7. PUMP INSTALLATION 17, (SYSTEM REPAIR L' OTHER O DISTANCE TO NEAREST: SEPTIC TANK _.. SEWER LINES DISPOSAL FLD. PROP. LINE .— c FOUNDATION _ _ AGRICULTURE WELL _ OTHER WELL PITS/SUMPS INTENDED USE 1 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L' Industrial f D Open Bottom J Manteca Dia. of Well Excavation _ Dia. of Well Casing LJ Domestic/Private 0 Gravel Pack Ll Tracy Type of Casing Specifications ! Priblic Cl Other 1.1 Delta Depth of Grout Seal Type of Grout__ _ • I I Irrir gation 1 Approx. Depth I Eastoin Surface Seal Installed by_ - -- -State Work Done • Repair Work Done U' T.ype.of Rump; -- - ..•_N.P. : -- - - --- -. - _ . 1 Well Destnrction I-] Well Diameter Scaling Material (top 501 ` - } r Depth Filler Material (Below 501 ; • TYPE OF;SLPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I (No septic system pcnnnled it public sewer is .".. 1. l available within 200 feet.) X„Installation will serve: Residence—Commercial 3 20ttter ..._.-. _ �•---�-.- : - Number of living units: _ _� Number of bedroo f Character of soil to a depth of 3 feet: R�_ -- - _—Water table depth-- SEPTIC epth -SEPTIC TANK 0 Type/Mfg _ Capacity No. Compartments PKG.' TREATMENT PLT.❑ `? Method of Disposal _ " "Distance to nearest -4 Well, � Foundation Property Line_ LEACHING LINE t V"-No. & Length of lines —�d'- TTo�y_l.l_ength/size QT 'FILTER BED . ; EJ Distance to nearest: Well�O .— FoUriliatibh u Irroperty Line SEEPAGE PITS ( I I Depth '- - Size _-u -.-- Number SUMPS r Distance to nearest Vyell Q_ Foundation _ _ Property Line L -�_�— DISPOSAL PONDS CI f I hereby certify that 1 have prepared this application and that ttre work will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin Local Health District,,.____ 10.. Home owner-or)leer)"sed`aeerii's sigiiafilre certifies the following: ': certify that in the-performance of-the work for which this permit is issued, I shall nc employ any pefson iii such manner as to become subject to wbtkman's compensation laws of California." Contractor's hiring or sub-contracting signatut certifies the following: "I certify that in the performance of thA work for which this permit is issued, 1 shall employ persons subject to workman's compens< tion laws of California." The applicant must all for all qu'red inspections. Complete drawing on reverse side. Title: _jam _ Date: t 9-h 7 Signed X— _ - _ �;. ` _. /yam SFO EPARTMENT USE ONLY t �/�...�� — Date _ ^ Area Application Accepted by _ - _ Pit or Grout Inspection by __ Data Final Inspection by Additional Comments: y,i f I Stk 466-6781 tJ Lodi 369-3621 D Manteca B23-7104 ❑ Tracy B35-6385 Applicant . Return all copie'slo:'Erivironrtrental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 ' FEE., AMOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED BY DATE PERMIT NO. INFO - I L: . EH 1324(REV.r/N`! �n EH 14-2E