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APPLICATION FOR PERMIT SAN J0A0U'.,1 1__OCAfi P`A!TH DIS i ENViI�Ci'Ih: v�� a ;. TRfC SAN JOAQUIN LOCAL HEALTH DISTRICT S 1 t ,'=i T�r OMSION 1601 E. HAZETON AVE., STOCKTON, (;A4 . Telephone (209) 466-6781 f� r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) lication is heieb made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is APP Y made in compliance with San.11oaquin County Ordinance No. 549 for sewage or No. 1862 for welllpump and the flutes and Regulations of the San Joaquin Local Health District. I� LW C City Lot Size PM Job Address 4137 ^a ,� r `r lAh r f hone r Owner's Name e_ dresJ f [ /'C/�T sG /� r l / N Contractor s Address �r� Ut C License �04&�4 � Phone d TRUCTION ❑ TYPE OF WELL/PUMP: 'I� NEW ELL WELL REPLACEMENT ❑ DES PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERA f' oNfJDr�lnfC� wELL ,I. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE . FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t t El Industrial ❑i�Open Bottom Ll Manteca Dia. of Well Excavation .Z Dia. of Well Casing t ❑ Domestic/Private ravel Pack ❑ Tracy Type of Casing P Specifications Type of Grout�/ nrQ�' e f"7 Public I� Other I�Delta Depth of Grout Seal _,, -�-- I I ! Irrigation ��..Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done [IType of Pump H.P- State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 — �r-a�4l1JbQ1jTplZjN(�OLLL Depth Filler Material (Below 501 NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I I (No septic,�,stem;permifted f;;public sewer is TYPE OF SEPTIC WORK: I I 1 bl�wifh�;r�n 200 1et104 '`J4 Installation will serve: Residence— Commercial, Others Number of livingunits: Number of bedrooms Character of so ��to a depth of 3 feet: a�tet ta61e dept SEPTIC TANK ❑I I Type/Mfg Capacity No. Compartments_ –. ! •..r",.L _11-1 t't PKG. TREATMENT PLT. [a [»�Mt8odr jf5Disp`bsar Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ ! No. & Length of lines Total length/size j FILTER BED ❑ 1 Distance to nearest: Well Foundation Property Line f SEEPAGE PITS I I! Depth Size Number SUMPS ❑'I Distance to nearest: Well Foundation Property Line r 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, a rules and regulations of the)San Joaquin Local Health Di%trict. 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 Califor ia." il.1 The applicant st call forall r it ins s. Complele drawing a reverse /(0 /5 Signe tJIL 7itla: S Date: FOR DE ENT LY Application Accepted by Date Ar ov Pit or Grout Inspection be Dateg� Final Inspection b Date Additional Comments: II ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Il FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. I INFO ♦,EH 13-24 MEV.r/n s� � `QO I-A.Ci `� �♦� ., EH 14.26 I f �I