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APPLICATION FOR PERMIT C SAN JOAQUIN LOCAL HEALTH DISTRICT V 1601 E. HAZELTON AVE., STOCKTON, CA / Telephone (2091 466-6781 _ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) �LR/Lf�—�-> .ation is heteby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is .ve in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin vocal Health District. �/� 9 9.S2Yo Job Address (' " 'V '�'+ ° LCity — Lot Size a U) PM Owner's Name #I pp Ad ress z"I Phone — U/ r,e {i/- Contractor Address to License No.,,'�0779-1 Pho O? 7f- 23e 6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER W TH;G'chb, 4/ed DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 3' Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing K-�.S Specifications I"1 Public ❑ Other ❑ Delta Depth of Grout Seal /a011 Type of Grout I I Irrigation 34='pprox. Depth 1 I Eastern Surface Seal In by cd,Atm•zar _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 (� TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I PINO septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG.TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 rules and regulations of the San Joaquin Local Health Dttltrict. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or subcontracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Comp a drawing on reverse/sy��J t /� SignedX ////e5x � G/��l I JZ A,16 �G Q/A7tsc/ Data: G FOR DEPARTMENT USE ONLY Application Accepted by Date Pit Gro Inspection byn Ir 9J M� Data d Final Insspectioznn by�-�`�-y0/ /A ArC Dwe L4 Additional Comments: (_1JNSn� SOL Woe—A, a1A73�02 2 ( �orLc llMMm� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7100 ❑ Tracy 8366385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE S'Qf/Y'r�a INFO ,y{A("M�/OjUNT DUE AMO/UNIT REMITTED CK RECEIVED BY �j DATE PERMIT NO. . EH t}z4IREv.rixoi Y'n /Ds OD 7L/ ! U EH 1418