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t a APPLICATION FOR PERMIT ; - `" " SAN JOA LOCAL HEALTH DISTRICT I 1601 E. HAZELTON,AVE., STOCKTON, CA Telephone(209) 466-6781 PERMIT EXPIRES 1,YEAR 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. 1$62 for well/pump and the Ryles and Regulations of the San Joaquin :Local Health District. T F T # s * 1 g�D E -,e/i'� r+ Kiri � Loi Size �14C PM Job Address _ w 1?.eB�,P k JJ1I Address; SBS E = Phone ^O O Owner's Name �s-.�.�_ Contractor �ry` Address -a 6 License No. 7/- Phone I TYPE OF WELL/PUMP: a NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑`f SYSTEM REPAIR ❑ OTHER ❑ ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION '� AGRICULTURE WELL ! OTHER WELL PITS/SUMPS I INTENDED USE' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ❑ Industrial y El Open Bottom 11Manteca Dia. of Well Excavation `. Dia. of Well Casing ❑ DomesticlPrivate LJ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ' El Other V' �14 C1 Delta Depth of Grout Seal- ` Type of Grout c Elv 46 0aIrrigation --Approx.-Depth ❑ Eastern Surface Seal Installed by Repair..Work Done -.❑ Type.of.Pump i H.P. State Work Done Weli Destruction , ❑ Well Diameter"- I. Sealing Material (top 501 4 Dept { Filler Material (Below 50')TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r available within 20.0 feet.] - 0/ F • Installation will serve: Residence_ Commercial— Other - Number of living units: --Number off bed-rooms11 14 1•-- _� t � v Character of soil to a dept of 3#eet: �. Wage table depth , > SEPTIC TANK Irk-jType/Mfg `�-= F Capacity- 0 t No:(Compartments 4 PKG. TREATMENT PLT- 11 '�`:d � Method'of Disposal a ro ,}. Distance_toinearest:�ell_�-_�—,Foundation 149� Property;Line. .-- �: rt Total len th/size LEACHING LINE �Nb:&-Lerigth of lines , r 9 -a � 4. FILTER BED ❑ Distance to nearest: Well �.0 Foundation•.. Property Line 40 SEEPAGE PITS `Depth Size r Number r SUMPS ❑Distance to nearest: Well Foundation f'3l! Property Line I 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 la v,'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 woikman's compensa- tion laws of California." The applicant must calil for all required inspections. Complete drawing on reverse side7. , ,. �.. _.�..«. Date: .�— �i - Signed - Title: FOR DEPARTMENT USE ONLY Application Accepted byr. Date Area f Pit or Grout Inspection by Date 5`31`t'v� Final Inspection by �e ��° A4ditional Comments: , P` V Stk 466-EM1 ❑ Lodi 369-3621 11 Manteca 823-7104 ❑ Tracy 835-6385 t A licant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t al - FEE AMOUNT DUE- AMOUNT_REMITTED CASH RECEIVED BY DATE PERMIT"NO. INFO + EH1324 REV.ad.8.51,- -.=.Y. _ -.•-. -..-.-«.•—ri-*.---a...�.+r..- ( �q -�b' / q EH 1426 I -�