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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTQN AVE., STOCKTON, CA Telephone {209} 466-6781 ,,.... PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or 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." P Job Address /7 33 V M City Lot Size PM Owner's Name Address f Phone . s Contractett/u' �r - ou.lt LO Address�� License IiojZVZ� �e Phone3��RS/a1` TYPE'OFrWELL-/PUMP: NEW WELL ❑ _µ F„ WELL REPLACEMENT ❑ DESTRUCTION E1_— i ., .R _ PUMP INSTALLATION LlwX SYSTEM REPAIR ❑ OTHER per'= Y- DISTANCE TO NEAREST: SEPTIC TANK . LINES' T DISPOSAL FLD. �s PROP. LINE ' s FOUNDATION AGRICULTURE WELL OTHER WELL �`" PI`TS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom --,❑ Manteca Dia. of Well Excavation _ Dia. Well Casing -E l Domestic/Private ❑ Gravel PackS� ❑Tracy Type of Casing specifications M Public ' : ;,on Other I-Abelta Depth of Grout Seal Type of Grout '+3�I I Iriiyatiori t.�q --Approx. Depth I 1 Eastern Surface Seal Installed by 3 r Repair Work Done �❑ Type of Pump H,P. State Work Done_ J Well Destruction ❑ Well Diameter Sealing Material (top 50') _J Depth Filler " I IBelow 501) k TYPE OF SEPTIC WORK:' NEW INSTALLATION lel REPAIR DDITION DESTRUCTION l I,(No septic system permitted if public sewer is. s v f available`within 200 feet.) Installation will serve: Residence_ Commercial— Other �^ Number of living units: Number of-' d ooms ' AZ _ Character of soil to a depth of 3Wfeat:,el" ' _ _ Q F —,- Water table depth SEPTIC TANK 0-"Type/Mfg x p rf;i YP 9 Capacity -:No'"Compartments PKG. TREATMENT PLT. ❑ j , i r Sa'�j r Method-of-.Disposal N Distance to nearest: Well SCS Z Foundation ff�roperty,Line. .�F LEACHING LINE No. & Length of lines Total length/size_ X r FILTER BED ., ❑ �Di�tance,lo-nea►est: Well �' a.. F,oundaiion_.� Property Line _," SEEPAGE PITS I� Depth S 'Size_ �3 Number SUMPS L� Distance to nearest: Well /66Foundation /C? Property Line _ .S— DISPOSAL PONDS ❑ -.r 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 whichthis permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." t a. The applicant cail for all rd ire inspections. Complete drawing on'reverse side. Signed X 1 Title: ►/ 1"' Hate: �U FOR DEPARTMENT USE ONLY Application Accepted by Date V, Area it 'r Grout Inspection by�.� `� ate Final Inspection by Date Additional Comments:A rje-.-_� ig" /tet �823-7�104 �r7 ❑ Stk 466 fi781 ❑ Lodi 369 3621 ❑ Mantecy 835-6385 G d L Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazaiton Ave., P.O. Box 2009, Stk., CA 55201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY PATE PERMIT"NO. INFO CASH + EH 13"24 1REV.I/H s! EH 14-20