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vEtl APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRIC 1601 E. HAZEL T ON AVE. STOCKTON CA Telephone (209) 466-6781 : J PERMIT EXPIRES TYEAR FROM DATE ISSUED LNVtRO ryTp,t- V4EAt..T14 (Complete in Triplicate) �F4C�flCa Application is hereby made to the San Joaquin Local Health District for permit to construct and/or install th¢utn3rk�� ,y pp q p erein described. This application is made in compliance with San Joaquin County Ordinance Na.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address / T City 4®421 Lot Size PM Owner's Name • /V !T Address ;� _- Phone Contractor W.5 Address.,;1�a /,1ZCl4.l' ,t?j�License No. Phone r � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION ❑ I PUMP INSTALLATIONW,eV,4 PSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:-SEPTIC TANK. Z.SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIONS AGRICULTURE WELL_�F �. HER•WEL_L-" INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack d Tracy Type of Casing Specifications C!� f"1 Public / Other Delta' Depth of Grout Seal Type of Grout I I Irrigation _.-Approx. Depth I "Eastern Surfer a Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. —_ f ZState Work Done /yr,E I Well Destruction ❑ Well Diameter - .� Seating Material (top 50'I Depth,- _ Filler Material (Below 50 TYPE OF SEPTIC WORK: NEW'iNS- ALIL TION, REPAIR/ADDITION I I DESTRUCTION l I Wo septic system permitted if public sewer is a available within 200 feet.) I Installation will serve:.. Residence_ Commetciat I pt#aer. S1, ' Number of living units: Number of bedrooms ��-. x,� Character of soil to a depth•"of-3-feet. �_ -- > - �' Water table depth i SEPTIC TANK 0 Type/Mfg Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ c'� j; t } Method of Disposal r Distance to nearest:, Well "foundation Property Line "LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well IFounilation Property Line I SEEPAGE PITS I I Depth Size E Number 4 SUMPS Ll, Distance to nearest: Wello�untiation Property Line �DISPOSi4L'PONDS"'"' ,r- ❑. 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 i rules-and-regulations-of-the-San Joaquin Local--Health.-Di§trict. - - - — -� --- 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." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work fof%�hich=Ihis permitxs issubd�_i shall employ persons subject to workman's compensa- tion laws of California." -�=�I .— N ?".�`�: l The applicanto. s eF 'II req ui ns. Complete drawing on r e. w QQ s Signed X tile: C J Date: 7LZ U LJ i _ 7 FOIJ DEPARTMENT USE ONLY Application Accepted by Date__71 -0 o Area Pit or Grout Inspection by � � Date Final Inspection by Date Additional Comments: l ❑ Stk 466-6781 ❑ Lodi 369-3621 .r ff 1ganteca a23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK 9 INFO AMOUNT DUFEE E AMOUNT REMITTED CASH RECEIVED BY DATER P�ERJMIT'NO. +.EH1321 tFiI:V.r/w 51