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F ' APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT A 1601,E.+HAZEL T ON AVE-, STOCKTON, CA Telephone 666) 466-6781 PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED " ,,J ' (Com . plete in Triplicate? Appfication_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 Juin 'Local Health District. "` �w•�,�- J-•��. . oa4 { bob �•n:t, }eft, 10 ' Job Address } '4..�/ - 0 1x Lot Size PM Owner's Name r Address I fl 1�P 5 1 U Phone f Contractor OGS `�"1t'l� st�. Address �. IZX 1 p � 'T� ""q .;.. License No. G- w Phone *-, —� 0.4 TYPE OF WELL/PUMP: NEW WELL'D, a WELL REPPLAENT 1-1DESTRUCTION ❑ f P,UMPINSTALLATION El❑ -SYST6M-} AIR OTHER ❑ f , M y DISTANCE TO NEAREST: SEPTIC TANK DSRk9R-LINE!9--N DISPOSAL FLD, PROP. LINE a FOUNDATION AGRICULTURE WELL _�THER WELL PITS/SUMPS INTENDED USE TY -OF-WEL-L"""""PROBLEMAREA CONSTRUCTION 64CIFICATIONS` ✓ t 1 ❑ Industrial ❑'Open'Bottom-"'"�""O Manteca Dia. of Well Excavation Dia. of Well Casing .. Domestic/Private 0.Gravel"Pa�k�,, Tracy Type of Casing .�,a at S rt t Public Ll Other t pecifications ❑ Delta Depth of Grout-Seal Type of Grout + -i ❑'f'frrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑., Type of Pump H.P. State Work Done i Well Destruction ❑ 'Well Diameter Sealing Material (top 50') Depth Filler Material {Below 50'} TYPE OF SEPTIC WORK: NEW INST LLATION REPAIR/ADDITION ❑„ DESTRUCTION ❑ (No septic system - p permitted if public sewer is + � P� �� available within 200 feet.) 3 Installation will serve: Residences commercial f -1.OtFier- t , 4 Number of living units: Number oedraoms ` t '"t `ti d Character of'soil to a depth-f 0f4et::• �. � Water table depth I ~SEPTIC TANK Type/Mfg Capacity!00 No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disosal Distance to nearest: Well Foundation 10 Property Line (17 LEACHING LINE . No. &Length of lines' �l _ Tptal length/size FILTER BED C1Distance to nearest: Well�-- Foundation fU �" Property Line _� ) tr SEEPAGE PITS ❑ Depth Size umber j SUMPS V Distance to nearest: Well Foundation t D- Property Line DISPOSAL PONDS ❑ � � � I I hereby certify that I have prepared this application and that the work will be done in accotdance with San Joaquin county ordinances, state laws, and k rules and regulations of the San Joaquin Local Health District. r ' 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 for which this permit is issued, I shall employ persons subject to workman's cdmpensa- tion laws of Cal'fornia.,, The applicant st all for all require ins tions. Complete drawing on reverse side, y (� Signed Title:0V 4V � CAft_ \ a Date: FOR DEPART ENT USE ONLY Application Accepted by Date rea + 4 fift or Grout Inspection by Date ? Final Inspection by Date C] Additional Ciimments: -` �•- ❑ 5tk 466�78i Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy $35 8385 i Applicant - Return all copie o: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. + EH 13-24 SREY. /B5) EH M28 Ivs✓• 7 u'{f'~g3 7 r ' J i