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-0. .l APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA V 1 Telephone {209) 466-6781 V 1 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 instal 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. .fob Address ✓?3 N City_c 57V440mA_�ot Size --9 At'/ie,�' PM Owner's Name f-" Address.5V.33/11 r .�� Phone g ' Ulo Contractor VeF y Address AVVIdwie AQIR License No 3� Phone TYPE OF WELL./PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ _ SYSTEM REPAIR OTHER LJ 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 . ❑ Industrial ❑ Open Bottom ❑ Manteca f Dia-'of Well Excavation Dia. of Well Casing. ❑ Domestic/Private 1 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i t"1 Public 1-1 Other n Delta Depth of Grout Sealy i Type of Grout _, Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by " { Repair Work Done ❑ Type of Pump H.P. - �Y .t.StateWork Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 z Depth Filler Material {Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is v , available within 200 feet.) �yv � Installation will serve: Residence_ Commercial— Other t , Number of living units: Number of bedrooms j Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No."Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ' Distance to nearest: Well Foundation Property Line 1 - I LEACHING LINE ❑ No. & Length of lines 9 Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ! I Depth Size Number SUMPS Cl 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 i rules and regulations of the San Joaquin Local Health Diltrict. All, { 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."Contractors hiring or sub-contracting signature I certifies the following:"I certify that in the performance of the work for which this permit is issued,{.shall employ persons subject to workman's compensa- tion laws of California." 1 1 The applicant ust call for all required inspections. Complete drawing on reverse side. r ; Date: 67`G-&= 7' 1 Signed X Title: r' l FOR DEPARTMENT USE ONLY t Application Accepted by Date { Area ` I Pit or Grout Inspection by Data Final Inspection byAn Date I( r✓7 J i Additional Comments: (f�i7 hDTS�[L�P� Ij (rjfj SS 1Z- g- rg ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmentaf Health Peimit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE INFO AMOUNT DUE JAMOUNT REMITTED SASH RECEIVED BY DATE PERMIT'NO. +. EH 113-24 IREV.5/x 5) �*1`r J /� L—A-`�� / _lz 'MEH,10-28 J I �1 1CU �( I !