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APPLICATION FOR ,PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT,' 1601 E. HAZELTON AVE.,:-STOCKTON,-.C'A Telephone (209) 46 64%-0 I ' PERMIT EXPIRES ''YEAR FROM DATE-ISSUED F (Complete in Triplicate) Applicationis hereby made-to+the San Joaquin Local Health District for a permit to construct and/or install the work herein'_tlescribed. This application is i 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.` Job dress �zL ��-7,5- Lam" r Rw __ City�7� Lot Size��-�jttZr PM . �,.� Owner's Name_ 9l Address r Phone Contract&AL� sxf%c ;nnz4&F'_ Address Al 7 Z7License No. �eZZ Phone 2 �23d TYPE OF WELL/PUMP: NEW WELL R1 r` WELL REPLACEMENT ❑ DESTRUCTION O �. " STALtSYSTEMRfPA4R-L� +IER-©wPUMP-IN � � - ---_ _ .w..._-.r,DISTANCE,TO-NEARES,T.:wSEPTIC TANK :SEWER LINES_ 5 -_ DISPOSAL FLO PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �. . - �` ❑.Industrial . ❑ Open Bottom El Manteca Dia. of Well Excavation Dia: of Well Casing ,b Domestic/Private (C Gravel Pack 11 Tracy Type of Casing[ } Specifications w ('1 Public (7 Other Cl Delta Depth of Grout Seal f fJ ___ Type of Grout__, I I Irrigation Qc,,DApprox. Depth I ) Eastern Surface Seal Installed by _ M Repai';Work_Dane ❑ Type of Pump SACH.P. State Work Done{ Well Destruction' ❑ Well Diameter j . Sealing Material (top 50') Depth Zero Filler Material (Below 5011 - p - TYPEf OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION I ) INo septic system permitted it public sewer is v� available within 200 feet.) Installation will serve: Residence— Commercial_-_- Other i Number of living units: Number of bedrooms " Character of soil to a depth of 3 feet: i �-Water tabled pth SEPTIC TANK---� ~ 1-1f Type/Mfg I Capacity No.,Compart ents PKG.-TREATMENT PLT. ❑ � � .y Methodof Di osal Distance to nearest: Well Foundation "PropertVline ' { ,LEACHING LINE Cl No. & Length of lines a — ,T^*aI_length/size FILTER BED ❑ Distance to nearest: Well a Foundation Prope'-rty ine%. SEEPAGE PITS I I Depth Size t Number `"S U M PS =13isgance- -riearest:c---Welt Foundatmon perty-Line DISPOSAL PONDS ❑ 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 I 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 foriwhich!this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's 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 compansa- tion laws of California." The applicant must call for all.rreegquired inspections. Complete drawing on reverse gide. i Signed Xf �. Title: � Date: FOR DEPARTMENT USE ONLY [ a 6✓ L r 1� Area 1 -2- Final Application Accepted by Date gut Pit orInspection by ate Final Inspection by Dat Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazeltoh Ave., P.O. Box 2009, Stk., CA 95201FEE I INFOEAAMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT N0. r+. * EH EH`14 26[REV.,i x 5f Ot5 / t% S e C. w—, lrlly h� OU .