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APPLICATION =OR PMMIT SAN JOAQUIN LOCAL HE -',LTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED PERMIT NO, �44D cV9 D - DATE IS -SUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install ,.he work herein described. This application is made in compliance with 5 n Joaquin County Ordinance No, 549 for sewage or No. 1862 for well/pump and the Rules and Regulations �o� .he San Joaquin 1_ and lth 'sI ict, Job Address ,.l��1!�� !�rLb vision Name Owner's Name Address _ _ _ _ Phone Contractor's Nam .a cense No. / �5'C ,'3" Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL. REpLACFMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 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 SPECIFICATIONS J Industrial ❑ Oper bottom ❑ Manteca + Dia of Well Excavation ❑ Domestic/Private ❑ Gravel Pack (7 Tracy Dia. of Well Casing _ ❑ Public 0 �j h Del. 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 as to become subject to workman§ compensation laws of Cali`ornia." Contractor's hiring or sub -contracting signature certifies the following: "I certify that in the performance of the work for which this permit i5 issued, I all employ e. ns subject to workman's compensation laws of California." The applic t mb ;call or /q spections. Complete drawing on reverse side. / J Signed r G'' /' Title: Date: 7 --- Application Accepted by FOR CEDARTM�Area ❑ Stk 466-6781 Additional Comments: _ E] Lodi 369-3621 Pit or Grout Inspection by _ _ Date Manteca 823-7104 Final Inspection by,[ nn�� Date y ❑ Tracy 835-6365 Applicant - Return all copies to:. Environm al Realth Permit/>�rvices 1601 E, Hazelton Ave., P.O. Box 2009, Stk „ CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITT O 1 RECEIVED BY SATE 6r;PERMIT NO. 3 INFO — — —� — — EM 13-24 REV, 10/82 -- — f JYj j { 11 (� 101112 500 14-26 &3 • t er❑ a Type of Casing Irrigation —� Approx. (- Eastern Specifications ❑ Cathodic Protection Depth _ Depth of Grout Seal ❑ Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth _ _ Filler Material (3elow 50'') TYPE OF SEPTIC WORK: NEW INSTALLATION 2-"fREPAIRIADDITiON ❑ (No septic tank or seepage pit permitted if public sewer is - available within 200 feet.) Installation will serve: Residence J!!!f Commercial Other Number of living units: Number _ of bedrooms_ Lot size_ Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK P-1 lype/Mfg _ Capacity ! j r} No. Compartments — - -- PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal — SEWAGE SYSTEM L� _ Cistance to nearest: Well _ Foundation 12,1 "'Property Line z DESTRUCTION _ LEACHING LINE j No. 6 Length of _ lines Z'_ Total length/size FILTER BED t ❑ Distance to nearest: Well Foundation Property Line ---� SEEPAGE PITS CI Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation 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 as to become subject to workman§ compensation laws of Cali`ornia." Contractor's hiring or sub -contracting signature certifies the following: "I certify that in the performance of the work for which this permit i5 issued, I all employ e. ns subject to workman's compensation laws of California." The applic t mb ;call or /q spections. Complete drawing on reverse side. / J Signed r G'' /' Title: Date: 7 --- Application Accepted by FOR CEDARTM�Area ❑ Stk 466-6781 Additional Comments: _ E] Lodi 369-3621 Pit or Grout Inspection by _ _ Date Manteca 823-7104 Final Inspection by,[ nn�� Date y ❑ Tracy 835-6365 Applicant - Return all copies to:. Environm al Realth Permit/>�rvices 1601 E, Hazelton Ave., P.O. Box 2009, Stk „ CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITT O 1 RECEIVED BY SATE 6r;PERMIT NO. 3 INFO — — —� — — EM 13-24 REV, 10/82 -- — f JYj j { 11 (� 101112 500 14-26 &3