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--w C,40 L, APPLICATION FOR P MIT _ i y SAN JOAQUIN LOCAL HEALTH DI _ STRICT r I F 1601 E. HAZELTON AVE.,�STOCKTON, CA �pi'JIV�Y` Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C'h��. _..,,(Complete in Triplicate) f' 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. c n ` 41 - i "Jit t_ !c• Job Address 2 �C Li 1FtDc�> t. T.i, ; r" ��CK7Z? �� r - City 4ot Size 14 PM Owner's Name L L=Z - G 5" Address _5�� E Phone OO Contractor 2LZGkLE�SL .60r- 7Cddres s :,P QW, - )NI Cly License No. 08.). Phone._&3__Ssn TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION A (CULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL r �RROBLEM+AR CONSTRUCTION SPECIFICATIONS : ❑ Industrial ❑..Open-Bottom C] Manteca `` a: of W-11-Ezcav`aiion Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type f Casing ti.Specifications. d ❑ Public ❑ Other ❑ Delta Depth of out Seal i Type of Grout Q Irrigation _gpprox. Dept ❑ Eastern t Surface Seal tolled by Repair Work Done ❑ Type of Pump - "S w . (�. H.P. State Work Done F Well Destruction ❑ Well Diameter ' "• ! Sealing Material (top 50') 1 f Depth r',f Filler Material.(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION El:-DESTRUCTION (No septic system permitted if public sewer is i E 3 f ` ailable within 200 feet:l ! Installation will serve: ResidenceCommercial.._ Cr"Other 1A 11i Number of living units: Number of bedroomi t n «_ 66raatdrof-soif-to a depth of 3 feet: 17Vater table depth:' SEPTIC TANK ❑ %Jype/Mfg >i z '- Capacity x_1"`�'� No. Compartments PKG. TREATMENT PLT: ❑ Method of:Disposaf Distance to nearest: W611-~.^�, �I Foundation Property Line 1 Jam_ R LEACHING LINE ❑ No. & Length of lines "rte 4 Total length/size FILTER BED ❑ Distance to nearest: Well -Foundation Property Line - SEEPAGE PITS ❑ Depth' { - Size ; Number SUMPS ❑ Distance to nearest: , Well — --a-Foundation---- Property Line DISPOSAL PONDS ❑ k l 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 t rules and regulations of the San Joaquin Local Health District. t.,• + _ t - 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 t employ_any-person•in such-mannei as-to-become-subject-to-workman's compensation laws of California.' Contractors-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 compansa- tion laws_of_California.' The applicust p for;Mired quired inspections. Complete drawing on reverse side. Signed X Title: Date: 7PARTMENT USE ONLY Q Application Accepted by gi I hqlN Date V Area Pit or Grout lnspection�by Date Final Inspection by Date Additional Comments" ❑ Stk 466-6781 Y ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.,Box 2009, Stk., CA 95201 t _ FEE INFO AMOUNT DUE AMOUNT REMIT-TEDK RECEIVED BY DATE PERMkT'NO. h Y+ EH 13-24IREv.)ia5t � J ',� •" ��l - -r r^ I EH 14-29 ! KJ a /^r