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j APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 , f PERMIT EXPIRES TYEAR 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 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. j� i7p �� 3 5 (� 4 O a •City -Lot Size `001 1*149 1(PM Job Address Owner's Name Volt„f c C Address 94`3r` ' ”} a �CP�f} Phone ContractorC +fir�`g Address 2CSGI�i�M�r6� License fro. ��°t m Phone TYPE OF WELL/PUMP: NEW,WELL ❑ WELL REPLACEMENT 171TR DESUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK s SEWER LINESDI` SPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE-WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLFM AREiC CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private Cl Gravel Pack Tracy Type of Casing Specifications ("1 Publics ❑ Delta. Depth of Grout Seal Type of Grout I I Irrigation a Appio Depth Yl ! Eastern Surface Seal Installed by - Repair Work Done L3 Typeof P mp _ H.P. State Work Done _ if Well Destruction 1 ❑ Well Diameter Sealing Material {top 501 ter~ Depth Filler Material IBelow 50') (TYPE OF SEPTIC WORK: NEW INSTALLATION I'1- REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet-1 R Installation will.serve: Residence'_ Commercial— Other ` Number of living units: -A—. 'Number of bedrooms b�� edrooms —.Character of soil to a depth of 3 feet:-9Water table depth G� SEPTIC"TANK t tEl` Type/Mfg �DA1 �1�L' Capacity j(OL- No. Compartments PKG, TREATMENT PLT. ❑ �., l/� �_, ^ � Method of Disposal I al I i. Distance to nearest: Well Foundation�� Property Line CP LEACHING LINE Gr-No. -No. & Length of lines �t _Total length/size r FILTER BED El :,Distance to nearest. Weil' Foundation 3� f Property Line �d i SEEPAGE PITS Y f'� Qepth x ?J 'Size _Number SUMPS L-1 Distance to nearest: Well Foundation 0 f t Property Line ao -DISPOSAL PONDS ❑ w '" 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 rules and regulations of the San Joaquin Local Health District. I 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 4 employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the.work for,which this permit is.issued,-1.shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for I req ored inspections. Complete drawing onreversereverse side. Signed X Title: +F a wa Date: `a 2 ~ i FOR DEPARTMENT USE ONLY ; r t 1 Application Accepted by_ o� Date 1�-: �� Ar�aevj"t.A VT /� f/ bt or Grout Inspection by Date 1�L/6 A ' al Inspection y 1 Date Additional Comments: 0 Stk 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.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT*NO. �. + EH 13-24fREy.J/85l /� "Y7 F � �7 EH 14-28 ^