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;r " APPLICATION FOR PERMIT SAN JOAOUIN LOCAL HEALTH DISTIh%, T .601 E. HAZELTON ON AVE., STOCKTON, CA Telephone 1200; 466.6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED rr (Complete in Triplicate) Application is hereby made'o the San Joaquin Local Health District for d permit to ronslruct and/or install the work herr,in dnar,rihed. this application.s made in compliance with San Jcayuin County Ordinance No.F.19 for sewage or No. 1862 for w1dl/pump and the Rules and Regulations Of the San,loaquin S ??cel Local Health D,stnCt. - A x .,t,-.,n• �� G City_T�',�c4 LP ot Size_ -- ,1" Job Address F e � OS Address _- — ___ Phone ,�I. ✓ __ — t Owner's Name : _Address— 1��rL ,d�— License No.: Jf.LPh.une _ > Contractor TYPE.OF WELL,PUMP: NEW WELL 1_I WELL REPLACEMENT f 1 DESTRUCTION L) i I PUMP INSTALLATION C) SYSTEM REPAIR 1-1 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES -- DISPOSAL FLD.—._ PROP. LINE FOUNDATION _ =AGRICULTURE"'ELL OTHER WELL PITSiSUMPS _ i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom C] Manteca Dia. of Well Excavation ___ Die.of Well Casing t• ❑ Domestic/Private 111 Gravel Park ❑ Tracy Type of Casing Specifications 1'1 Public ❑ Other F] Delta Depth of'Grout Scal _— Type of Grout___ - w I I Irrigation __Approx. Depth l I Eastern Surface Seal Installed by -- f; Repair Work Done [J Type of Pump H,P. — State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Fi;14,Material (Below 50') -- W TYPE OF SEPTIC WORK: NEW IN! REPAIR/ADDITION I I DESTRUCTION I i (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units--�— Number of bedrooms , Water table depth Character of soil to a depth of 3 feet: KQ -- � � —_P I / Cap acir/ — No. Compartments -- SEPTIC TANK Ll Type/Mfg Method of Disposal PKG. TREATMENT PLT ❑ i�tc,�A du — Distance to neared: Well�� _ Foundation lProperty Line, — — 1r_——Total length/size_L+—�� ) LEACHING LINE No. 8 Length of linos _sem - j lot' 1 FILTER BED ❑ Distance to nearest: Well Foundation s1 Property Line SEEPAGE Pl S I I V apth _ e Number I SUMPS �+{ Distance to nearest: Well/Lbv-�t- Foundation_-�!n—r— Property Line._ d�� •'r+�s+�. DISPOSAL PONDS /❑ r I hereby certify that I have prepared this application and that the v+ork will be done in accordance with San Joaquin county ordinances,state laws, and ,pf. L I rules and regulations of the San Joaquin Local Health Diistrict. not Home owner or licensed agent's signaturn certifies the following:"1 certify that in the performance of the work for which this permit is issued,I shall me sub;act to workman s compensation laws of California."Contractors hiring or sub contracting signature ' f employ any person in such manner as to becot certifies the following:"I certify that in;he performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa• }}. 9 tion taws of California." ` The applicact must call for requi d ins p e ctions. Complete drawing on reverse side. +? ,} Title: ', -� —_ oats: L� 1 FOR DEPARTMENT USE ONLY 4•'{ P' _ Date D Area �rig Application Accepted by Pit or Grout Inspection by Date_ Final Inspection by Additional Comments: /JO O Stk 466-6781 ❑ Lodi 369-3621 ❑ M niece 623-7104 ❑Tracy 835-63135 yJ I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,CA 95201 FEE AMOUNT DUE AMOUNT REMITTED SASH K t RECEIVED BY DATE PERMITNO. INFO C �o�,� .EH 1324 IREV-Vi—5i EH 1/-2e ( ! .r--l.-, ...-W mraiu,.+..,.+rawatww`.mu>:.w••+Nr+.F.•rrl+�i7obewwrltrFMlGYrrt9iti1a6G:r�+xr�.u6irwww�w M�.ntia•:v/.�•;.•Kys;+rF-i4&y ,n, •v.rw.u;K•,:'S:vMewe+C•w.�,.:....rn ..........w••u...-..-,...:, - �� _;1: r