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q a ' r `APPLICATION FOR PERMIT I i SAN JOAQUIN'LOCAL HEALTH;DISTRICT € f 1601 E. HAZELTON AVE.; STOCKTON, CA Telephone; (209) 466-67811 , 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 San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin 1 Local Health District, Job Address City Lot Size Salme� 4i PM r.. { 6 Owner's Name Address Phone Contractor MAI 'Adi ress[ License No. f%3, Phone�� TYPE OF WELL/PUMP: P1 NEW WELL.C]. WELL REPLACEMENT `❑ DESTRUCTION ❑ PUMP INSTALLATION D SYSTEM REPAIR 'O OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP..LINE FOUNDATION AGRICULTURE W4-/—- OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREACON RUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ MantecaWell Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Casing Specifications i f l Public Cl Other C] Delta f Grout Seal Type of GroutI Irrigation _.Approx. Depth l I Eastern vSurface'Seal Installed by Repair Work Done L3 Type'of Pump >, H.P. ! State Work Dane Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth T Filler Material (Below 501 _ TYPE OF SEPTIC WORK: .NEW INSTALLATION!_ }.REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.] ' Installation"Will-Serve: Residence! Commercial Other . Number of living units: Number of bedrooms__ Character of soil to a depth of 3 feet: Water table depth 1 ' SEPTIC TANK CIType/Mfg `f Capacity No. Compartments'/2 PKG. TREATMENT PLT. ❑ I r Method Dispos Distance to nearest: Well-1U� Foundation" / Property Lino' 'U LEACHING LINE L] No. & Length of lines _ Total length/size--7_ FILTER BED ❑ Distance to nearest: ell Foundation- 2 Property Line 7_ VZkL- IV SEEPAGE PITS I l Depth Size Number SUMPS L]" Distance to nearest: Well ;'Foundation Property Line DISPOSAL PONDS ❑ E 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. 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 Iaws'of California," Contractor's hiring or sub-contracting signature rh 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 applicant ust all formol required nspections, Complete drawing on reverse side. SignedX Title: _ �_ Date: F R DEPARTMENT USE ONLY I Application Accepted by �;_ -/ Data 2� S Area Pit or Grout inspection byII Date Final Inspection by �ra-�d?'L— Date 67 Additional Comments: l,,kf� e6/ ❑ 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 FEE CK T INFO AMOUNT DUE �pAMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. ..EH 13-24(REV.r/051 �V' k (c, EH EH:4.29 '�-