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f APPLICATION FOR PERMIT i k C ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA i 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. I ( ` Job Address ig 5• �Iexo IttzQ- Lah�s` City L-0 '` �'` ` Lot Size PM ' Owner's Name UAddress 1.2Z� �— Maf1� sr• UtkFT ��d ,T[yPhone -Ak-- ` Contractor T relv>~ Address old Z License No. Phone TYPE OF WELL/PUMP: T NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Industrial ❑ Open Bottom ' ❑ Manteca Dia. of Well Excavation OvkM Dia. of Well Casing Z ❑ Domestic/Privat ❑ Gravel Pack '__ ❑ Tracy Type of Casing ��V% Specifications''I 7r 71 Public Wil i� Other !- 11 Delta Depth of Grout Seal �� Type of GroutJX can(, ❑ Irrigation�"y4f 00J-1___Approx. Depth ❑ Eastern Surface Seal Installed by 4 Repair Work Done ❑ Type of Pump t H.P. State Work Done Well Destruction ❑ Well Diameter ¢ Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted ifipublic sewer is available within 200;feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a deptfi of 3 feet: i° - ~ _ Q Water table depth SEPTIC TANK ❑ ,Type/Mfg Capacity No. Compartments M PKG. TREATMENT PLT. ❑ ., P, Method of Disposal i Distance to nearest: Well Foundation'- Property Line �( LEACHING LINE ❑ No. & Length of lines---j Total length/size FILTER BED Cl Distance to nearest Well r Foundation ' '` Property Line SEEPAGE PITS' ' }❑ 'Depth Size ' Number SUMPS M 11 Distance to nearest: Well Foundation Property Line 6 DISPOSAL PONDS D --,., 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. -, . ,#,, l 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."Contiactor's Hiring or subcontracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,-).shall eriiploy'persons subject to workman's compensa- tion laws of California." 1 The applica ust call for all required ins ctions. plate drawing on reverse sideo- ' ,.� Signed Title: Date: RTMENT USE ONLY I - Applicatich Accepted b Date Pit or Grout Inspec y',, to Final Inspection by Date f_ _ Additional Comments ❑ Stk 466-6781 L01 369-3621 ❑ Manteca 104 ❑ fracy 835-6385 Applicant- Return all copies to: Envir n ental �ea,��j,Perm�ynit/,Seff`''ices 1601 E. Hazelton ve., P.O. x 220009,5t�A 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CASH G + EH 13-24 fREV.t/65) ll L-i E1,1111-26 l