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APPLICATION FOR PERMIT ; SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZEL T ON AVE.,{STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED" I Corr(pi46'in°Triplicate? , I"b io " 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 Ryles and Regulations.of the San Joaquin Local Health District. n .;. .-..C}""f,�%l3.i`�. , k .. # ,. ,;�...•'�„^��,[+•ice,., [ ,. :_, -. , } - Job Address �2 L I E Vi City-f� C' l lot� `4ot Size QPM Owner's Name C V S Address Phonett - Contractor lc=�, WA L��ddress S icense No. hone TYPE OF-WELL/PUMP:”" —'—""'NEWWEL'L--C]--""-WELL REPLAi'EMPI T-❑ ,DESTRUCTION'L—' PUMP INSTALLATION ❑ _ SYSTEM REPAIR:❑ ,r OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS —INTENDED.USE TYPE-OF-WEL-L [eATIONS—r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation '° ; Dia. of Well Casing {� r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing-..4 Specifications ❑ Public E3 Other ❑ Delta Depth of Grout Seal Type of Grout q ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by, k I Repair Work Done ❑ Type of Pump H.P. t State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 I r Depth Filler Material {Below 50) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION QL-DE-STRUCTION ❑i1No septic system permitted if public sewer is ;available within 200 feet.) Installation will serve: Res' ence VlCommercial_ Other Number,of living units: Number of bedrooms s * k Character of sotl to a depth of 3 feet: _ _��1�. �j _ _ Water table depth SEPTIC TANK ❑ Type/Mfg Capacity 1 No' Compartments PKG. TREATMENT PLT. ❑ ( ry Method of Disposal Distance to nearest: Well Foundation` Property Line ' a L t C-\ � LEACHING LINE N--1Vo. & Length'of lines ' "' Total length/size; 40 FILTER BED ❑ Distance to nearest: Well Foundation 'PropertynLine SEEPAGE PITS ❑ 'Depth Size Number SUMPS i�.-f istance to nParest:_....,�Well. ,.Foundation+ Property Line DISPOSAL PONDS ❑ 16)( 4x& I 1 hereby certify that I have prepared this application and thaf 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. �� [ 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 I employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature G certifies the foilowing:"I certify that in the Wormance'of the irvork'for which this petmit is issued,I shall employ persons subject to workman's compensa- tion laws of California. The a t t m tall fo all uire spe n Complete drawing o reverse lde. Signed Title: �� Date: FOR DEPA E USE ONLY r # Application Accepted by r # Date r Pit or Grout Inspection by � "�' Date' Finer Inspection by DateVAlfd t Additional Co rn ments:, y ❑ Stk 466-Ml O`Lodi 369-3621 ,. � ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Av ,.P.O. Box 2009, Stk., CA 95201 r jINFO FEE AMOUNT DUE, AMOUNTiREMITTED - -(CK H - -RECEIVED BY DATE (PEERMIT`NNO. + EH 13-24(REV.r/ae) ,� - �O [-[.P1 2-9Zz--PS- EH 1428 I } t .� r