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a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �P�ACFYES 1601 E. NAZELTON AVE., STOCKTON, CA Telephone (205) 466-5781 OCT 2 G 1937 PERMIT EXPIRES 'I YEAR FROM DATE ISSUED (Complete in Triplicate) 1/IRONMENTAL HEALTR Application is hereby mane to the San Joaquin; Local Health District lot a permit to construct and/or install the work herein descroftimisaviczis made in compliance with San Joaquin County Ordinance No. 549 lot sevrage or No. 1862 for well/pump and the furies and Regulatrrins of the San Joaquin Loral Health District. of size ___.y _ ---_• PM Job Address &,vnet"s Nam � tsfess t r � .�r-j� l Ph/o✓ 'n i` r�� _ Y OF SEPTIC WORK: NEW INSTALLATION i'i REPAIR;ADDITION i : DESTRU installation will serve: Residence— Commercial Nurnbw of living units: Number of bedrooms Character of soil to a depth of 3 feet:.. SEPTIC TANK F! Tyl*�Mfg PKG. TREATMENT PLT. C Distance to nearest: Well LEACHING LINE 7, No. & Length of lingo FILTER SED +_I Distance to nearest: Weil Other fNo septic systern perrnitled if public sewer is available within 200 feet.) _._........, �..._......_ Water table depth _-.. Capacity No. Compartments . Maltxad of Disposal . foundation Property Line.- Total Foundation . ___ Property Line .. ....._......._--- SEEPAGE PITS _ I S Depth .._......... Number SUMPS Li Distance to nearest; Weil Foundation Property Line DISPOSAL PONDS C t hereby certify that i have prepared this application and that the work will be done in accordance with Sari Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Nome owner or kicerised agent's signature certifies the following: "i certify thst io 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 laves of California." Contractor's hiring or sub -contracting signature crartifws the foikrwing; " 1 certify that in the performance of the work for which this permit is issued. I shall employ persons subject to workman's crrmoensa- tion laws of California." The applican est call for all required i pections Complete drawing on reverse side. 01 1 Signed X �� :.� tr1. - >1 Title;e 1 .�.. A Date: FOR DEPARTMENT USE ON' Y Application Ac by �`�' -�i� Date Area -- -- t-�C�__�a ✓ Pit or Grout Inspection by Date Final Inspection by-� r Date 3 y ...."v Additional Comnyants: Z? i_' Stk 466-6781 C L i 365.3621 C Manteca 823-7104 Tracy 835.6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E: Haxation Ave.. P.O. Bots 2009, SStk„ CA 95201 a . EN 13.24 tREV, t: >+t £te 14 26 FEE AMOUNT DUE INFO AMOUNT REMITTED License No. _ __ -- Phone � RECEIVED BY TYPE OF WELL/PUM : NEW ELL l: li WELL REPLACEMENT C DESTRUCTIONi PUMP INSTALLATION J SYSTEM REPAIR C OTHER Ill ""DISTANCE TO NEAREST: SEPTIC TANK ._ SEWER LINES _.. DISPOSAL FLO. - _ PROP, LINE - FOUNDATION __. AGRICULTURE WELL OTHER WELL -_._. _ _ PITS/SUMPS _ __..... INTENDED USE USE _..... ...._..... _. TYPE OF WELL _ ..__._._ PROBLEM AREA CONSTRUCTION SPECIFICATIONS l L Industrial D Open Bottom O Manteca Dia. of Welt Excavation Dia. of Well Casing _._....�..�� Cl DomesffeiPrivate G', Gravel Pack Cl Tracy Type of Casing Specifications `"' Putaiic [7 other [.-I Delis Depth M Grout Se -al Type of Cirout ! Irrigation _.___ Approx. Depth I Eastern Surface Seal Installed Repair Waik Donn 0 Type of Pump H.P. ._..._._....... ...... _.. _ State Wn gone t' Well Destruction X Well Diameter _ _ Sealing Material trop 501' P3i Depth Filler Materia} (Below 501 _.. —..._. _. OF SEPTIC WORK: NEW INSTALLATION i'i REPAIR;ADDITION i : DESTRU installation will serve: Residence— Commercial Nurnbw of living units: Number of bedrooms Character of soil to a depth of 3 feet:.. SEPTIC TANK F! Tyl*�Mfg PKG. TREATMENT PLT. C Distance to nearest: Well LEACHING LINE 7, No. & Length of lingo FILTER SED +_I Distance to nearest: Weil Other fNo septic systern perrnitled if public sewer is available within 200 feet.) _._........, �..._......_ Water table depth _-.. Capacity No. Compartments . Maltxad of Disposal . foundation Property Line.- Total Foundation . ___ Property Line .. ....._......._--- SEEPAGE PITS _ I S Depth .._......... Number SUMPS Li Distance to nearest; Weil Foundation Property Line DISPOSAL PONDS C t hereby certify that i have prepared this application and that the work will be done in accordance with Sari Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Nome owner or kicerised agent's signature certifies the following: "i certify thst io 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 laves of California." Contractor's hiring or sub -contracting signature crartifws the foikrwing; " 1 certify that in the performance of the work for which this permit is issued. I shall employ persons subject to workman's crrmoensa- tion laws of California." The applican est call for all required i pections Complete drawing on reverse side. 01 1 Signed X �� :.� tr1. - >1 Title;e 1 .�.. A Date: FOR DEPARTMENT USE ON' Y Application Ac by �`�' -�i� Date Area -- -- t-�C�__�a ✓ Pit or Grout Inspection by Date Final Inspection by-� r Date 3 y ...."v Additional Comnyants: Z? i_' Stk 466-6781 C L i 365.3621 C Manteca 823-7104 Tracy 835.6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E: Haxation Ave.. P.O. Bots 2009, SStk„ CA 95201 a . EN 13.24 tREV, t: >+t £te 14 26 FEE AMOUNT DUE INFO AMOUNT REMITTED K RECEIVED BY DATE PERMk't'N - --