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wo 3 7e44- APPLICATION FOR PERMIT SAN JOAO,UIN 'LOCAL HEALTH DISTRICT 1601_E. HAZELTON�-AV-E., STOCKTON, CA Telephone (-209) 466-6781 PERMIT EXPIRES'VYEAR FROM DATE ISSUED (Complete in Triplicate) s ` '�` _ .gt" ,: Application is hereby made to the Sari Joaquin Local Health District for 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 Ryles and.Regulations of the San Joaquin "Local Health District. - FS' .- ..-4 4 1A,, 71 � ��,: : ��.: tow k, Job Address 27040' _ ,s #:�citye+i'S7ze ,:r,: ta �, ;� ^PM . q""Owner's Name -Address Q` ec shone Contra ll,-Gi i iti. Address. A �9"D` '7'� 1�r7�3 y®E7'�7'� License No. __ Phone TYPE OF V§IELQI/ UMP:_ NEW'WELL'❑"`"--'�"" ""WEi L REPLACEMENT 0, - DESTRUCTION _. r PUMP INSTALLATION ❑ SYSTEM REPAIR,=r--'_`� OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL BITS/SUMPS INTENDED USE,A, TYPE OF WELL PROBLEM AREA ;CONSTRUCTION SPECIFICATIONS s ❑ In stria) ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia of Well Casing •- . [!1' mesiic/Private ❑ Gravel Pack ❑ Tracy Type of Casing c ' `Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigationprox. Dep ❑ aster n r Surface Seal Installed by Repair Work Done p H.P. State Work Dpne Well Destruction N meter Sealing Material (top 50') P T' t r ,, �//Depth �•�''� Filler Material (Below 50') '~ rte' ,e TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ . REPAIR/ADDITION ❑ DESTR TION ❑ (No septic system permitted if public sewer is available within 2004&e)' Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartmenfq PKG. TREATMENT PLT:❑ Method of Dis al Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines 4 Total length/size { FILTER BED ❑ Distance to nearest: Well Foundation Property Line ` SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well 'Foundation .: s Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that;the Work,will.be_dorie.in'accoidance wiih San"Joaquin county�o�dinances}state laws, and rules and regulations of the San Joaquin Local Health District, y ' 3 Home owner /cense gent's signature certifies the following: "I certify thatxin t__helperformance`of the work for which this permit is issued, I shall not employ a •person in suc manner as to become subject to workman's compensation laws of Calif ornia.""Coni"rector's hiring'or sub-contracting signature certifie he following: "I rtrfy that in the perfor c of ork for which this permit is issued, I shall employ persons subject to workman's compensa- tion I of California. rr '+. � 4 The pp can mus' If all requi I pie d M te drawrn e e de. Sign d 1 �'- Ai Title: - -_.Date: FOR DEP TMENT USE ONLY �. Application Accepted by ` Date /,Z— Pit or Grout Inspection by Date Final Inspection by - Date lanal"Comments: " I' tk 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.0° Box 2009, Stk., CA 95201 FEE a INFO AMOUNT DUE, AMOUNT REMITTED CASH - RECEIVED BY DATE PERMIT,`NO. ♦ EH 13-24(REV.1/85} EH 14-26 `1 9r1 - • r .. I