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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601. E. HAZE T ON AVE., STOCKTON, CA Telephone (200) 466 -Ml PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Jti�re�C 9'f - Q2 (a X 3. a 'y. ;,.i ; .,. s� (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a made in compliance with San Joaquin. County Ordinance No. 549 foewage or No. construct and/or install lite work herein described- 7} a Local Health District. r �� 8F ,kve }/pump and the Rules and n n o-� rAJ`,fll Regulations of the San Joaquin Job Address. . City- - Lot Size PM ' Owner's Name, Address ` "12?�- Contractor _ PFioneAddress5 TYPE OF WELL/PUMP; License No. Phone NEW WELL ❑ WELL REP ENT ❑ PUMP INSTALLATION DESTRUCTION ❑ Q SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK_ OTHER C1 �. FOUNDATION _ SEWER LINES �` DISPOSAL FLD._ AGRICULTURE WELL PROP. LINE INTENDED USE O Industrial TYPE OF WELL _ OTHER WELL_ PROBLEM AREA CONSTRUCTION SPECIFICATIONS PITS/SUMPS _ ❑ Domestic/ Private ❑ Open Bottom - + C Manteca " Dia. of Well Excavation C Public C Gravel Pack _- ❑ Tracy Type of Casing_ Dia. of Well Casing ❑ Irrigation's ❑ Other ' ❑Delta Depth of Grout Seat Specifications ---Approx. Depth Q E — , Type of Grout astern Surface Seat Installed by Repair Work Done 1 -1 Typ Well Destruction e of Pump _ H. P. — State Work Done t C Well Diameter — Depth Sealing Material (top 50') Filler Material (Below 50') ~� TYPE OF SEPTIC WORK: NEW INSTALLATION r, REPAIR/ADDITION ❑ DFSTNUC IJUN Q (No septic system permit[ Installation will serve: Residence ' - available within 200 feet.) Commercial _ Other Number of living units: 4—Number Character of soil to a depth of 3 feet: SEPTIC TANK O Type/Mfg "' J Water table depth PKG. TREATMENT PLT. ❑ Capacity 'No, Compartments Distance to nearest:Method of Dirgo Well — Foundation, -3-0--. Property Lih if public sewer is v LEACHING LINE) No. &Length of lines- FILTER ines ` S/, FILTER BED —�� Total lengthJsize T O Distance to nearest: Well - Foundation �� Property Line 'ice SEEPAGE PITS;� r Depth... -ro ❑ —, ✓ . Distance to ne...umber . .Weft Q bISPOS"AL PONDS "❑. r: �' 1,% Foundation ,%��_ Property Line I hereby certify that I have prepared this application and that the work will be done in accordance with San Jo rules and regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following:equip county ordinances, state laws, and Y'Person employ ahefollowi in such manner as to become subject to workman s�co compensation laws of Caajifornia Contractor'he work for lhiringch ' or sub contractt'ng signature ' certifies the following: �permit is issued, t shad not g: " I certify that in the performance of the work for which this permit is issued, 1 shall employ tion laws of California."4 i p y persons subiect to workman's compensa- «r The applicant must call for all 'red inspections. Co plate drawing on averse side. ' Signed Tale: J Date: FO DEPARTMENT USE ONLY Application Accepted, by p r( Date Pit r Grout I -'�Q/ rea Inspection by Date 3� P Final I rlapectloh by Date CJ Additional Comments: ❑ Stk 486-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 " ❑ Tracy 8355-638.5 f' •� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazetton Ave., P.O. Box 2009, Stk., CA 95201 I »I FEE AMOUNT DUE INFO AMOUNT REMITTED EH 13-24 Mv. i 8 5) EH 14-28 , —co ti RECEIVED 6Y DATE PERMIT'NO. "i } r