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t S ,J APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 f'Y 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 S_an 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. yt Job Address I City Lot Size Owner's Name .�5 � lJ \ \ Address Phone ContractorS LJe� ddress. �5W " SSL Wr�cense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑Zk WELL REPLACEMENT ❑ " DESTRUCTION ❑ i __.'...:.-_P_UMP_JNSTAL-LAT1_b SYS+EM_REISAIR❑""""'_"- �r-OTFIER❑ _:.�. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE � O'U�VDATfON"" "7�GRlCULTl1RE'Vti/ELL�" OTHER WELL PITS/5L1MPS F INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , i j ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.-of Well Excavation Dia of Well Casing ❑ Domestic/Private` ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Deltas Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth C7 E8s_tern�/= Surface Seal Installed by 1~' Repair Work Done ❑ Tvbe of Pump .�H�PState Work Done Well Destruction . D. Wlt,Diameier Sealing�Material Itop 50'I { Depths ' i Filler Material {Below 501 TYPE OF SEPTIC WORK: fNEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permrtteld if public sewer is' 1 / available within 20d feel} ter�`t` Installation�ivill serve:/Residence_ Commercial_4�Other - Number of living units: Number of bedrooms, t. Character of soil to/a depth of 3 feet: .i _Water table depth 1 '` 1 SEPTIC TANK { ❑ Type/Mfgµ -- ;ham ^ ; Capacity No. Compartrjients,�. PKG. TREATMENCl Method of Disposal.,, FjPLT.PLT Distance to nearest: Well Foundation Property Line LEACHING LINEN ❑' Nit: &-Length of lines Total length/site FILTER BED !L1Distance to nearest: i Well Foundation Property Line f t a 1 SEEPAGE PITS 11 ILD Depth Size Number I t SUMPS; 11f ❑:K Disiance to nearest: Well Foundation Property Line' DISPOSAL PON6S1_ i j• ❑ I hereby certify tta t hhave 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 District. l f l Home owner 4r Ifcensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not fe employ any person in such manner as to become subject to workman's compensation laws of California."Con'tractor's hiring or Aub-contracting signature certifies the foilo%i ing: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject io workman's compensa- tion laws of California." The applic ust call for all r q it inspections. Complete dfawing on reverse Signed ide. 9 Si Q 9 i itl Date: i ^ �FOt PARfiMENT USE ONLY l /Application Accepted by Date r '~ Area v �- 4"i , Pit or Grout Inspection by Date Fina! Inspection by / ' Date-j -___r}� Additional'Coinrilents: ,- �— �O 5[k,r466-6761 ❑ Lodi 369-3621 _LI Manteca---823-7104$ "❑,Tracy 8356385 rk n Applicant- Return all copies to: Environmental Health„Permit/services 1601 ENazeiton Ave., P.O. Box 2009, Stk., CA 95201 •k'i� FEE CK INFO AMOUNT DUE AMOUNT REMITTED /A�SSH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.I/H 51 J �. 43S©'•'�„ !1/I/� –�yj S-1-57 _1._..5 7 70 EH 1428 _ /,` /" / [,T do,--/