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e; APPLICATION FOR PERMIT SAN JOAQUIN LOCAL"HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telej ne (209) 466-67Sr1 PERMIT EXPIRES t YEAR FROII'il 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 Rgles and Regulations of the San Joaquin Local Health District.tr Job Address %t1 �a Citylr�� Lot Size PM Owner's Name V Ik-14I.Q Address. 513 Phone Contract AddressLicense No29A "" TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT`.❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. - PROP. LINE FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well,Excavatign- Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing' Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation pprox. Depth ❑ Eastern Surface Seat Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material ttop 50'1 Depth Filler Material(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted N public sewer is available within 200 feet.) Installation will serve Residence Commercial_ Other Number of living units:--.,4— Number op bedro ms. ZJA Character of soil to a deoth..af 3 feet: y Water table depth / V SEPTIC TANK ❑ 1 ype/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ - Mothod of Disposal Dist4pe to nearest: WdltFoundation Property Line LEACHING LINE Ik—No. & Length of tines Total length FILTER BED ❑ Distance to-nearest: WW foundation 10 Property Line f, SEEPAGE PITS ❑ Depth f $ "k Yumber SUMPS Distance,to neareq:,`� Wetlr�i 'Fou /� Property Line_,'2 DISPOSAL PONDS ❑ I hereby certify that I have prepared this application andthat the work will be done in accordance with San Joaquin county ordinances,state laws,"and• rules and regulations of'tf%San Joaquin Local Health-owfiri6 __ Home owner or licensed agent's signature certifies the following: '7 certify that in the perforrhance of"*Ork-for V006 t'his permit is issued, I shall not employ any person in such manner as to becomet swbject to workman's.compensation laws of California."Contractor's hiring or subcontracting signature certifies the following:"t certify that in the performan,ce.of the m"for vt cbxhW i iaepe¢;1 shat mployoimns subjectto workman`soampenw tion laws of California. The applican at call f all wined inspectionsmplete drawing on reverse Signed Title: Qom' ' FOR DEP RTMENT US f ONLY i T- ApplicationAcceptedby :;gate " Areaa�/� p r epectiori by. Date Final Inspection by' " O--Date �n Additional Comments: ❑ Stk 466-6781 ❑ Lodi 309-3821 -Q Manteca 823-A104 11'fraty 8354=4 _y Applicant-Return all copies to: Environmental`Hideo Pecrnit/Se6&es 1601 E. Haze` Ave., P.O. Bgx ,'Stk., CA 95201 P FEE !s INFO AMOUwr-DOE- -'AMQ1JNT 1; TTE0-', CASH RECEIVED BY DATE P9fMlf7NQ-: +EH 3-24(REV.1/85) t / EH 1 -26 . �' ••tp�