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i APPLICATION FOR PERMIT ' SAN JOAQUIN -LOCAL HEALTH DISTRICT ' 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 52091 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED l II (Complete in Triplicate) i . 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. Job Address — � City ),�eeLot Size PM Owner's Name = � e-.A 1 A6!q ddress Phone Contractor C�.« I� Address_- f V /�� -�Ir License No. lC� ione , -� F` TYPE OF WELL/PUMP: !i NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ V� —PIMP-INSTA-L-LATION,-❑._, ,. SYSTEM-REPAIR-13--'OTHER-❑-- 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LIN .f!!!� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS\_ INTENDED USE TYPE OF WELL A PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 11 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---approx. Depth -•❑ EasternSurface Seal Installed by - ' iii - •'"`8 ,. ",' 4.. .. r ` y. d - e Repair Work Done C] Type of Pump H.P. State Work Done Well Destruction 11Well Diameter„ Sealing Material Itop Depth �' '�^ s Filler Material (Below 501, � — { TYPE OF SEPTIC WORK: NEW INSTALLATION,0"-REPAIA/ADDITION DESTRUCTION ❑ (No,septic system permitted if public sew:er is '�n � !4 t 'y '' "available within 200 feet.) `Installation will serve:. Residence Commercial— Other - fad eyi� ; Number of living units: Number of bedrooms3a � k} Character of soil to a depth.of 3 feet: y —`—'Water-fable depth ' SEPTIC TANK • .Type/Mfg .Gly Capacity 1 !!E0f. No. Compartments PKG' REATMENT PLT. ❑ i 1 Method of DisposeI v Distance-to nearest:,. Well" - Fbuhdation � Property Lined A LEACHING LINE El No. & Length of lines �^7 D Total length/size FILTER BED ❑ Distance t ynearest:, Well....�0 Foundation Z�Property Line i SEEPAGE PITS ❑ De�ih �A /0Size ' � Number SUMPS C /Distance to nearest: Well 1 foundation Property Line DISPOSAL PONDS 5�1� .. I hereby certify that I have prepared this application and that the work will a 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: "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_Califomia.;�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 compensa- tion laws of California." The applint mu all fora equire spectio s. Complete drawing on reverse side. I Signed Title: --� ° ' "" .�Date: FOR DEPARTMENT USE ONLY Application Accepted by Date/'�✓��lr" / Area _ Pito rout Inspection by J U' Date� �Final Inspection by Date dA ditional�►Co �m�ents: �� -- � ❑ Stk 46G 67$1"""'""❑ Lodi;369'3621""""'"❑-Manteca'—&23-7144'�❑'Tracy 83554M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT''NO. INFO + EH 13-24 MEV.1 85) �p] EH 14-28 Pi _70 �}[X� 0�3 `. —