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--- y 30 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT + 1,✓ 1601 E. HAZEL T ON AVE., STOCKTON, CA V\ Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM 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 Rules and Regulations of the San Joaquin Local Health District. / Job Address .l3 2- bl, 46ALLWasl City �� Q of Size PM d +I Owner's Name 041 /" /_.( �_ Address Phone Contractor's NameLicense No. 7. 1 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑". `DESTRUCTION ❑ W PUMP INSTALLATION ❑ SYSTEM REPAIR ❑,,r OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE g —FOUNDATION- --_ AGRICULTUREWELL �% OTHER WELL PITS/,SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ 06eh-Bottom ❑ Manteca 4- .Dia. of Well Excavation Dia. of Well Casing ❑,Domestic/Private ❑ Gravel Pack ❑ Tracy , Type of Casing Specifications ❑ Public' ❑ Other_ _ ❑ Delta ro "' Depth of Gut,Seal T " _ p _ Type of Grout El Irrigation Approx. Depth Eastern f Surface Seal'I stalled by ; u Repair Work Done ❑ Type of Pump ! H,P, State Work Done `. Well Destruction ❑ Well Diameter x Sealing Material-(top 50') ; Depth f Filler.Material (Below 50') I',-\, TYPE OF SEPTIC WORK: NEW INSTALLATION•❑ r REPAIR/ADDITION 5i7DESTRUCTION ❑ (No septic system permitted if public sewer is 1 _•-' available within 200 feet.) Installation will serve: Residence_X-1commercial_ Other i V Number of living+units•. - / N"uu mber of bedrooms 7_3o Character of soil to a depth of 3 feet: 18 Water table depth + ) N SEPTIC TANK ❑ Type/Mfg "Capacity T- \No. Compartments i PKG. TREATMENT PLT. ❑ t Method of Disposal "F s Distance to nearest: Well Foundation 1 Property Line I LEACHING LINE No. & Length of lines Total Ingth/size FILTER BED ❑ Distance to nearest:' Well Foundation ! Property Line -- - . ' . _ •'� t �,1 a SEEPAGE PITS Depth c',_� Size <� Number SUMPS ❑ Distance to nearest: Well Foundation Property Line .� DISPOSAL.PONDS ❑T, r � I heieby-certify that I have_piepared 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. IV I 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 th&'work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." 'pie Thea licant t call for all pP quired ' ctio Complete drawl g on reverse side. Signed -�TTitle: ��-� _ Date: ~ R-DEPARTMY EN SE ON e I Application Accepted by . Date ""� Area Pit or Grout Inspection by � _xDate Final Inspection by / " ' * Date Arly r 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. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE r- INFO AMOUNT DUE, r. AMOUNTREMIT`ED��. t!C SH RECEIVED BY DATE PERMIT NO. + EH 13 24(REV.10/831 � � EH 1446 fl