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t APPLICATION FOR PERMIT --•---'- " SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED'".w., .. (Complete in Triplicate) of � !bf 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 sew_ age or No. 1862 for well/pump and,the Rules and Regulations of the San Joaquin Local Health District. v , ' " ' "` Job Address,r f ��Z)-,E, ,C L.. o J r City'L1 .jzh3 '.:Lot Size Ix 9 L PM -Owner's Name �` F-IPS p - ' Address �D U�ti�Q�(bl 1 Phone 7 .1 1 Contractor WALT AALL Co-S-1-St—, ddres's ''Jrd 'c' , AT' License No.4- 0-S,) Phone i j TYPE OF WELL/PUMP: NEW WELL ❑ r WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ (� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE `V FOUNDATION AGRICULTURE WELL OTHER WELL 1 PITS/SUMPS f. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private's ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public } 171 Other El Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by s r Repair Work Done ❑ Type of Pump H.P. State Work Done `+ Well Destruction ❑ Well Diameter Sealing Material (top 50'1 I P Depth Filler Material (Below 501 i k TYPE OF SEPTIC WORK:' NEW INSTALLATION ©/FTPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ,_ .,u• •1 available within 200 fell Installation will serve: Residence L--Commerll Other- j 3 -. moi l Number of living units: � Numbert of�bedrooms. -- Character of soil to a depth of 3 feet- _ C L Water table depth SEPTIC TANKL�gpe/Mfg CIn pi r- +�`; Capacity1:1 no No. Compartments(' PKG. TREATMENT PLT. � Method of yD�isyp/o}sa,l 1 Distance to nearest Well JECL Foundation Property Line ? LEACHING LINE 'tto-&Length of lines 5 Total length/size 1 70 FILTER BED E. .Distance to nearest: Well 1L FoundationI Property Line fDU� SEEPAGE PITS { t `'f[feptlh) Size Number. SUPS t t' _ ❑ Distance to nearest: Well_� Foundation �� P IVlroperty Line 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, and rules and regulations of the San,Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:A'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 c ifies the followi : "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 of Califo i �( The applican call r all uir ins _ .'ons omplete itla:ing on reverse — Signa :Date: FEPARTMENT USE ONLY O2Y 4 _ cam-I 7 Area U 'cation Accepted r� 4 Date tl = CP,)r- rout cti n Date or "1 ` Final inspection by 1 Date �T7 Additional,Comments: ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.Box 2009, Stk., CA 95201 I FEE r k. INFO AMOUNT DUE AMOUNT REMITTED CAH RECEIVED BY DATE ; PERMIT`NO. I + EH 24(REV.1/8 51 W 4- EH 1426 -• 4a