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.j APPLICATION FOR�PERMIT SAN JOAQUINIOCAL HEALTH DISTRICT a - 1601 E. HAZEL T ON AVE.,'STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (Complete in Triplicate) iI 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. i Job Address to �t` City ��/� Lot Size ��X �a PM /`1/9/ �Gd ,iQ,b`e!!.fll� Address fat%E_ Phone y Owner's Name ___ Contractor's Name 'ads elsh ,SGfl, l, License No. *� � 3 Phone L 9� � TYPE OF WELL/PUMP: II NEW WELL' ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑- ..mow SYSTEM REPAIR ❑ OTHER ❑ N DISTANCE TO NEAREST: SEPTIC TANK SEWER"LINES DISPOSAL FLD. PROP. LINE til ....w....FOUNDATION ,-AGRICULT.URE WELL-----OTHER:WELL-------__PITS/,SUMPS ' INTEN„DEt WSE TYPE OF WELL PROBLEM AREA'*"CONSTRUCTION SPECIFICATIONS n ❑ Industrial ❑ Open Bottom ❑.Manteca Dia. of Well Excavation pia. of Well Casing v ❑ Domestic/Private ❑ Gravel Pack _❑ Tracy Type of Casing Specifications ❑ Public s' El ❑ Other ./ 'Delta Depth of Grout Seal Type of Grout ❑ Irrigation ` _ - i1 ppr6 .TDepth- ❑ Eastern Surface Seal Installed by r Repair Work Done'❑ Type of Pump H.P. 1 State Work Done ; "Mil Destruction ' ❑ Weil Diameter Sealing Material {top 50'1 Filler Material (Below 501 TYPE OF-SEPTIC WORK: 'NEW INSTALLATION 7- REPAIR/ADDITION "ESTRUCTION ❑ (No septic system permitted if public sewer is ' available within 200 feet.) Installation will- Residence �Commeraial=Other Number of living units Number mber of bedrooms Character of soil to a depth'of 3 feetry V + Water table depth s SEPTIC TANK +� ��ype Mfg /�:�f.'lSfs�` J+ < < Capacity /, 61a �G � 'No. Compartments i PKG.TREATMENT LT.'_© --Method- P, of_Disposal.. _ ii. i :II stance to nearest: Well _ Foundation__._fes Property Line .5-1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation.- Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 1' DISPOSAL PONDS ❑ IF 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. F 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." II r f 1 I The applica call for all required inspections. Com late drawing on reverse side. Cy— Ir . � Signed Title:� � Date: S�Z 2 FOR-DNFA i Application Accepted by Datekr Pit or Grout Inspec on b !I� Date. �:` �� .Final,ln§pection by /J Qate � Additional.Comments:` ❑ Stk 466-6781 ❑ Lodi 369-3621! ❑ Manteca 82:3-7104 ❑ Tracy Applicant-Return all copies to: Environmental Health Permit/Services 1601 E.;Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO A►yMfOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY �7DATE¢ PERMIT NO. + EH 13.241REV.10!133) ! S_� EH 14-26 q - - •