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S �. . 4 n f d- I r' APPLICATIOWFOR PERMIT - 4 SAN JOAO,UIN.LOCAL HEALTH DISTRICT ` 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 ` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . . . µ �. .�� y(Complete in Triplicate) _Alp p-Ilication 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 t made in compliance with San Joaquin CountIy Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District" ^ _- > ro• 3:k' Iii - 1 , Job Address -� a-7 r'[.�lLI17A A �� - City Lot Size LO X ea PM Owner's Name 9,1_ ' PA TzI-E "a:aare-ss S Phone Contractor 6• LtI99-D Address L _ E License No.�YfY7 G Phone 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ - SYSTEM REPAIR ❑ B OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOU TION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF. PROBLEM AREA CONSTRUCTION SPECIFICATIONS l El Industrial El Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑• Type of Casing Specifications ` r L] Public EDOther S'D Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑'Eastern.; Surface Seal Installed by Repair Work Done ❑ Type of Pump - - HSP. State Work Done Well Destruction ❑ Well Diameter '"` w Sealing Material Itop Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTAL TION ❑• REPAIR/ADDITION ❑ DESTRUCTION INo septic system permitted if public sewer is �6 { --•� available within 200 feet.) f Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms I r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/MfgCapacity No. Compartments PKG. TREATMENT PLT. El Method of Disposal, Distance:to nearest: Well-- Foundation---� "rt Property Line ` LEACHING LINE e ❑" No. & Length of lines Total length/size wFILTER BED ❑ Distance to nearest: Wel Foundation Property Line SEEPAGE PITS ❑ Depth ; Size Number SUMPS ❑ { Distance to nearest: Well Foundation " Property-Line DISPOSAL PONDS ❑ R{ 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. 9 q 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 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 applicant must calf for all required:inspect" Complete drawing on reverse side. Signed Xc_—� l Title: _ _ Date: FOR DEPARTMENT USE ONLY Application Accepted by ' - Date L L Area Pit or Grout Inspection b Date Final Inspection by Date Additional Comments: ` ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mante 823-7104 171 Tracy 56385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE , AMOUNT REMITTED t RECEIVED BY ' DATE PERMIT"NO. INFO (l^ C�A7SH (� + EH 1324(REV.I/Rl I �J ' r C EH 14-20 r i