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M Lam. APPLICATION FOR PERMIT ... ',Vlk SAN JOAQUIN LOCAL HEALTH DISTRICT � 1601 E. HAZEL T ON AVE., STOCKTON, CA 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. r f �/ City Lot Size O/S' .QnS?1 PM R/ Job Address �O^�T�u C 14Z A o Owner's .Name T] -Bp�k Adds s��.� � C�� '-C I14 Phone � res Contractor S Address n. License No. Z y 'Phone Q t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LIDESTRUCTIONS.❑ # ! PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST:-SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE + : 3 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS CA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I-] Industrial ❑ Open Bottom 17Manteca Dia. of Well Excavation Dia. of Well Casing Type r I ❑ Dom�sticlPrivate C] Gravel Pack ❑ Tracy YP of Casing Specifications _ _ ❑ Public ❑ Other CI Delta Depth of f Grout Seal - Type of Grout' ---Approx. Depth LI Surface Seal Installed by- 0 y 9 ❑ Irrigation --app Repair Work Done C1Type of Pump H.P. State Work Done ` I Well Destruction ElWell Diameter Sealing.Material {top 501 ' WN &Depth a Filler Matenal'(Below 50'1 i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0 DESTRUCTION ® (No septic system permitted it-public sewer is „• available within 200 feet.) a . Installation will serve: Residence_L_ Commercial_ O h r • d' Number of living units: � Number of bedrooms$ Character of soil to a depth of 3 feet: Water Itable depih 0 d SEPTIC TANK ! Type/Mfg E 0t7 Capacity_ No. Compartmen_te I. PKG. TREATMENT PLT. EJMethod of Disposal + Distance to nearest: Well � Foundation !S Property 6;e./� •t Total length/size LEACHING LINE ❑ No'& Length of lines 4_ FILTER BED ■ Distance to neo"r{est:�lVell! Foundation%S Property Line k rl 4 1; SEEPAGE PITS EJ =Depth u Size ""'" 'Nijr:nber SUMPS FJ Distance to nearest: Well Foundation Prop" Line f � y 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-pDistrict. - : Home owner or licensed agent'ssignature certifies orm the following: "I certify that in the perfance of the-work for which this ermit is issued, I shall not . I employ any person in such mann.er 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,Vishall employ persons subject to workman's compensa tion laws of California." � { 4 The applicant must call for all required 'nspecti ns. Co plate drawing on reverse side. t Signed f Title: Date: i FOR DEPARTMO T USE ONLY Application Accepted by Data �ae ' Are /S i m Pit or Grout Inspection by Date - " 6 Final Inspection by 7- 6� Date 1 Additional Comments: j ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 r 9 Applicant - Return ail copies to: Environmental Health Permit/Services 1601 E. Haielton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 16Y DATE PERMIT N0. INFO CASH r�i 7. + EH 13-24IREV.1l8515 ff .+,�, t-� -: �1•els.-\ -:.„�` r EH 1428 •. i