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APPLICATIQN,FOR PERMIT F 1r� SAN,JOAQUIN,.LOCAL-HEALTH DISTRICT ; 1601*E.-HAZELTON 4E.,.STOCKTON, CA Telephone (209) 466-6781 € r, a ►. - x E PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. E (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. jj Job Address PY/��'�`/♦ / r i3 S I rC./e�WA o S z k PM f City Lot Size Owner's Name �� n Phone I Contracter F/pY1re�LrlfZp,ddress 1�I�1¢f'r��' " -- / B�3T 1 icense 049 S� Phone TYPE OF WEL /PUMP: NEW WELL ❑ -+b,,.,WELL-REPLACEMENT ❑ DESTRUCTION ❑ rs. PUMP INSTALLATION ED SYSTEM REPAIR ❑ OTHER , 5749/L IYISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . ' DISPOSAL FLD._ PROP. LINE FOUNDATION. AGRICULTURE WELL ' OTHER WELI °� PITS/SUMPS I— r INTENDED.-U.SE TYPE OF WELL PROBLEM AREA CONSTRUCTION•SPECIFICATI ❑Industrial t ❑ Oen Bottom ❑'Manteca. Dia. of Well Excavation 1 ' ¢ p Dia. f Well Casing ❑ Domestic/Private ❑ ravel Pack ❑ Tracy Type of Caso 0 S cification's ❑ Public a{�W10V `s Othergpjelt46-' ❑ Delta Depth of Grout Seal �a�� /,T� � '` ype bf Grout �r ❑ irrigation hdt" _ , Approx, Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. StaLe Work one Well Destruction. , ❑- Well Diameterf3 Sealing Material Itop 50') M Filler Material (Below 50') TYPE OF SEPTIC WORK: -NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer;is Q available within 200 feet.) f Installation will serve: Residence Commercial_ Number of living units: .- Number of bedrooms Character of soil to a depth of,3'feSt;t i . g ' .jI � �. .t Wateable e depth SEPTIC TANK ❑ Type/Mf � C" acitY No. Compartments PKG. TREATMENT PLT ❑ 3 Method of Disposal (\ Distance to nearest: Well Foundi-VA I. Property Line ' �1 � LEACHING LINE W ❑ No. &Length of lines � Tot I � - alength/size FILTER BED yam„ ❑ Distance to nearest: Well I E � � Foundation Property Line + SEEPAGE PITS' '4'4 ❑F Depth Size Y + Number + SUMPS 1714. Distance to nearest:- Well _ Foundation rty p Pro e Line f DISPOSAL PONDS ❑ M 1 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. a Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work fb%whichEthis permit is issued, I�s hall not employ any person in such manner as to.6ecome subject to workman's compensation laws of California."Contractor's hiring or sub-contracting Wnaturg/ 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." I r--k 1 The applic t re st II for all required inspections. Complete drawing on reverse si Signed dA� � '�3 l 1 `C'fy�teTitle: FOR DEPART ENT USE ONLY Application Accepted by f; Date .� I Area Pit or Grout Inspection by Date Final Inspection by ' Date Additional Comments: Ci Qri" ` P ❑ Stk 466-6781' ❑ Lodi 369-3621 ❑ Ma nt 104 . ❑ Tracy X835- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 - t . 1 � Y ._.., . INFO AMOCJNruuE AMOUNT REMfTTEI]"" CASH Y RECEIVED BY" "DATE -t PERMIT'NO. i + EH 13-24(REV.5/s 5) :+ Y #. kr V EH 14-28 4 •-"�, - t t1�/ pal I