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APPLICATION FOR PERMIT .ti. a, r - . SAN JOAQUIN 'LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES VYEAR'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. TMs application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Roles and Regulations of the San Joaquin Local Health Di ' t .. . .Jyurt ill' iJd- 1 ,� :'trsz d " P D9�1'�ISA 'Il rx-17. 6� Job Address —�� City Lot Size a S /9 PM -Owner's Name n tt If m"e.r r Address P)c Phone 7.39 3966y 4 ;.fit-- t:. ., i t Contractor k5 uGTb Address ■ License No. &L.?46 Phone 2- TYPE OF WELL/PUMP: NEW WELL ❑ WEL PL CEMENT ❑ DESTRUCTION ❑ PUMP'INSTALL-ATION❑ " %`SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEP ANT�� t SEWER LINES 00 f; DISPOSAL F PROP. LINE l06 t` FOUNDAT led -' -` AGRICULTU LL�� OTHER WELL/ntiI PITS/SUMPS /0 INTEND SE Taf OF WELL PROBLEM ARE t' CONSTRUCTION SPECIFICATIONS ❑ In ial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation "$`Z t A Dia. of Well Casing omestic/Private ❑.Gravel Pack ❑ Tracy Type of Casing _ Specifications .} ❑ Public C] Other ❑ Delta at Depth of Grout Seal Type of Grout ,th .� ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by V r Repair Work Done ❑ Type of Pump H.P. _ State Work Done (�j k Well Destruction ❑ Well Diameter Sealing Material (top 501 (1 Depth Filler Material (Below 50') V" TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) II Installation will serve: Residence✓ Commercial_ Other' Number of living units: /_ MNumber of bedrooms__._.a; L f / Character of soil to a depth of 3 feet: ~ S. f kA-z- AA Al Water table depth SEPTIC TANK Type/Mfg e r Q Capacity /2e B No. Compartments PKG. TREATMENT PLT. ❑ y 4 Method of Disposal l r Distance to nearest: Well ZdQ _Y_Foundation roe Line 9 D �, !: LEACHING LINE -No�& Length of lines "i? , -TotalJength/size FILTER BED ❑ ,.Distance to nearest: Well 2" Foundation ls/ Property,Line /so SEEPAGE PITS '11� Depth PS/. Sized *- = 'Number ' SUMPS LlDistance to nearest:X Well Foundation �o ( Property Line /da f'— DISPOSAL PONDS ! ❑ r 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."Contractors 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." ! ? The applicant must call for all required in ti ns. Complete drawing on reverse side. ` S` Signed X �Ft'A a.or..cd'�;.•1•or��,�s Title: FI-) Date: .s t 4-FOR DEPARTMENT USE ONLY i Application Accepted by L� �� ;��N Date 2—IS' � Area Pit or Grout Inspection by `/ _tFDate Final Inspection bye Date Additional Comments: r ❑ Stk 466-6781 Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 n' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201r i FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY - DATE PERMIT'NO. INFO CASH rREV. 5l �7 �. 41,