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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH �;STRIC'. II ; 1601 E. HAZELTON AYE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6),91 RATE ISSUED 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 thie woYk ierein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welt/pump and the Rules and Regulations of the San .oaquin Local Hea'.th District. Job Address l';-y sc'• FYP-46P-J<,R Subdivision Name , -- y FYec/Y '' Phone Owner's Name rr. 9J5170'0 Address xy3S S•o. 1c.IS• q �D� Phone .S-eT 3-ye'♦ P Contractor's Name �.e9.Y7miL �oA' License No. �✓yY-8'S�'/ - _ e� Ar Uj ' TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION J PUMP INSTALLATION SYSTEM REPAIR OTHER>Lj DISTANCE TO NEAREST: SEPTIC TANK i SEWER LINES- k..&I +� 0I$P05At FCO. •w��- PROP. LINE _ FOUNDATION --.j - -AGRICUL-TURE WELL—'^: "-'^ •OTHER WELL, - PITS/SUMPS.-7- Ul- INTENDED USE TY?E AF WELD PROBLEM AREA LCNSTRUCTION SPECIFICATIONS ' ; 3 (_( Industrial Lf Open Bottom Manteca Dia. of Well Excavation i h.(Domestic/Private []6ravel Pack Tracy Dia. of Well Casirgiyy 3V -� } # Q Public C Other. Delta Type of Casing f I Irrigation Approx. ff]-Easteft— S"--'""p ificat7 }- i [:]Cathodic Protection _._._� Depth i Depth of Grout 1411 (_i Geophysical i Type of Grout (-J Other ! Surface Seat Igstalled�by r 't-:'j 1•Y Repair Work Doric Type of Pump H.P. State Work Done 'dell Destruction LJ Well Diameter Sealing Material (top 50') ( Cept' Filler Material (Below 50') -_�C%-`%;`. � �0- f TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIR/ADDTTION (No septic tank or seepage pit permitted if.public sewer is available within 200 feet:)• �r Installation will serve: Resiaence _/ Commercial _ Other Number of living units: Number of bedroam3 " - .,-..Charecter-..of soil,-to-a-depth of 3 feet: S.Nn/fi/ _ Water table depth SEPTIC TANK Vj Type/Mfg Pim cooyg, Capacity Z.Soa_ No. Compartmentsz` PKG. TREATMENT PLT. V Type/Mfg Capacityl Method of Dispo `arrl; ~T1 f ` - 11 SEWAGE SYSTEM Distance to nearest: We11 foundation G Property Line DESTRUCTION r ` LEACHING ONE, tu. No. Length'of`Iini t,r Total length/size FILTER BED '+% ..^f: Distance t5-neaisdst.1 Well -,NrZ ndation Property;Line X�! SEEPAGE PITS, Depth Size Number - v SUMPS Ej- Distance to nearest: Well Foundation 9 Property Line 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 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 performance of the work for which this permit is issued, I shall not employ any person in such manner hs-to'•bEdome.aub•iect to workman s compensation laws of Callrornia." 1 Contractor's hiring or sub-contracting signature certiflesath8,folPowing, "1icertify that in the performance,of the work or which u� this permit is issued, I shall employ persons sdbject to workman's compensation la' 3'3f-PT ' " T e P The applicant must. cal for all required inspections. Complete drawing on eexerse side. -"�• s.-�+ Signed X_ -- -- Title: _.. FOR DEP RTMENT USE ONLY Area Stk 466-6781 i Application Accepted by l Additional Comments: _._..... — Lodi 369-3621 L Pit or Grout Inspection by i Oate ,/� `_ ��An`ecaB23-71D4 � "Fina nspection Sy Date -�P� '_' .racy 835-6385 Applicant - Return all copies to; nvironmental Health Permit/Services 1601 E. Hazelton:ve., P.O. Box 2009, Stk., CA 95201 t FEE BASE AMOUNT DUE AXOUNT-REMITTED RECEIVED BY DATE PERMIT NO.yj L O t C..r" t IV- j___ 1 1.� ...r�.:..�..-�..-�-----.^--"'--w-.'>'..---�r------•----r--^M'--...... �.......p......-•..---�- •i0J62-500 .�......�.r..•....... FH 13-24 RE V 7 U