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11�•)/1.�-c.-+1�'�— APPLICATION.FOR PERMIT V%' o — o i SAN JOAQUIN LOCAL HEALTH DISTRICT k--c"1-7 t 1601 E. HAZEL I ON AVE.,_STOCKTON, CA 1�,L Telephone (249) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED `` ` �L,-- s h'Uc haf k—rA- rr4j (Complete in Triplicate) I Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.TMs application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 18621 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.7� + Job Address City -Lot Size PIM �� 3 '' 1pwner's Name Address ��l��"�— Phone •S �T ontractor Address License No. Phone # r OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAR PTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �t FOUN AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL M AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial - ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type ing Specifications ❑ Public ❑ Other ❑ Delta Depth"of Grout a Type of Grout ❑ Irrigation �4pprox. Depth ❑ Eastern Surface Seal Installed by # Repair Work Done ❑ Type of Pump H.P. State Work Done WellDestruction ❑ Well Diameter Sealing Material {top 50'1 i Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is vailable within 200 feet.) s Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: " Water table depth t SEPTIC TANK ❑ Type/MfgCapacity No. Compartments PKG. TREATMENT PLT. ❑ f Method of Disposal f S_ Distance to nearest: Well Foundation Property Line i V LEACHING LINE ❑ No. & Length of.lines '�—�--W ` 9 � Total length/size- FILTER BED ❑ Distance to nearest: Well "" Foundation Property Line \ SEEPAGE PITS ❑ Depth Size }` Number SUMPS ❑ Distance to nearest: Well Foundation — Property Line DISPOSAL PONDS ❑ [, , 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 no?- 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, I shall employ persons subject to workman's compensa- tion laws of California." The applic t ust call for all requi d spections. Complete drawing on reverse side. Signed Title: 67ZZ~ ,' Date: J3 4F7 1` .o FOR DEPAIW USE NLY O�Application Accepted by Date4 Area Pit or Grout Inspection by, Date Final Inspection by Date Additional Comments . ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7144 ❑Iracy 835-6385 Applicant- Return all copies to: Environmental.Health Permitl.Ser ices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE I INFO AMOUNT DUE AMOUNT REMITTED" K RECEIVED BY DATE PERMIT'N0. + EEH 13-24 H14-2gIREV.t/a5Y (_ S` �� -