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APPLICATION FOR PERMIT sdf LF SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 11 _PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 1,90—op . w a. Application is hereby made to ha San Joaquin Local Health District for a permit to construct an install the work herein described. This application is - made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.. ©�+1 t`S%•i�:�... �rw4Y.� i�J e. City Lot Size _ l PM Job Address—, I Y �•j ��}r�S Addresstl�i�.rs� Owner's Name — . Contractor �� Address' +-Ar . 9,15 icense No lW_a B3— r"vn TYPE OF WELL!PUMP: NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑� r PUMP INSTALLATION C1 SYSTEM REPAIR O OTHER Fr 100'" DISTANCE TO NEAREST: SEPTIC TANK —S.{Zt�— SEWER LINES _ !;Q) DISPOSAL FLD. PROP. LINE 2& FOUNDATION AGRICULTURE WELL __ OTHER WELL _ PITS/SUMPS= (?1 INTENDED USE. El Industrial , G� Domestic/Private Fl Public I hrigation Repair Work Done L Well Destruction ) 17 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Y YL pen Bottom -- n, I Manteca Dia. of Well Excavation 13ravel Pack ❑ Tracy Type of Casing - Ll Other t] Delta Depth of Grout Seai 11W_Approx. Depth I ;Eastern Surface Seal Installsd by—_-. y— _-Type Typeof Pump H.P. — _ State Work Done _. Well Diameter — _ Sealing Material (top 501 -- - Depth Filler Material (Below 501 Dia. of Well Casing Specifications Type of Grout .r TYPE OF SFPTIC WORK: NEW INSTALLATION 11 REPAIR /ADDITION I I DESTRUCTION I I alvailao septic systern ble thin 200 rmttted rt puorrc sewer is Installation will serve: Residence Commercial _ Number of living units: —_- Number of bedrooms Character of soil to a depth of 3 feet: _ SEPTIC TANK O Type/Mfg -- PKG. TREATMENT PLT. ❑ Distance to nearest: Well Other II _ _._Water table depth_... Capacity No. Compartments - Method of Disposal - Property .Line Foundation LEACHING LINE 'Ll No. & Length of lines ___.- — Total length/size Fll TER BED LJ Distance to nearest: Weil �. Foundation _._. Property Line SEEPAGE PITS I ! Depth —Size _ Number SUMPS Ll 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's compensation laws of California." Contractor's hiring or sub contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The appltcan ust all for all required inspec ons. Complete drawing on reverse side. Signed XTitle:�2L+Y-- ��iiSP�S►CTc7( Dater�P�_. ' DEP RTAIIENT USE ONLY �q Application Accepted by Date �-"�L/ Q fZ Area .-- Pit or Grout Inspection by Date Final Inspection by Q I� Date Additional Comments: F] Stk 466-6781 I-', Lodi 369-3621 O Mant 823 7 11 Tracy 83 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009. Silt., CA 1 FEE AMOUNT DUE ARREMITTED CK ar CASH RECEIVED BY DATE PERMIT N0. INFO +.EH 13.241PEV. t,nyi 14 2e EH i r -