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S APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZEL IT AVE., STOCKTON, CA Telephone (209) 466-6781 A 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. r , - r 'i Job Address l/,Y s p rty C Lot Size c2_-&! PM 7 Owner's Name //V ,t V FAA) Address 3 ' Phone r�� r- - ..,� .....,.�T- - .s: ..r+ � /lJCT7.l� L r.✓�-.t"srr�!_.. .-!`-'E1� .,__,:fit..'.= ' - r... +^. Contractor Address License No. Phone_ TYPE OF WELL/PUMP: -NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ : BY F: t PUMP INSTALLATION ❑ e " `5Y5TEliA REPAIR ❑ OTHER ❑�? DIST TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL-•FLD.- --_—PROP: LINE , FOUNDATION AGRICULTURE WELL,`_ J OTHER WELL PITS/SUMPS INTENDED USE ._. E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' ❑ Industrial ❑ Open Bo"t`toln* ,�MJ„Ma tec Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy a Type of a n _ y Specifications ❑ Public ❑ Other I] Delta r -Depth of Grout Seal ""'" "= G„grout Ll Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. ' S State Work Done Well Destruction ❑ Well Diameter Sealing-Material (top 50') i Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is I T r `T available within 200 feet.! V l Installation will serve: Residence_ Commercial— Other - Number of living units: Number of bedrooms_ 1P t r( � Character of soil to a depth of 3 feet: � ��; - Water table depth .SEPTIC TANK ❑ Type/Mfg Capacity s No. Compartments {_PKG. TREATMENT PLT. ❑ ftp Method of Disposal 4 DistanceYto-nearest: Well Foundation 4- Property Line LEACHING LINE No. & Length of lines Total length/size `FILTER BED ❑ Distance to nearest: Well Foundaiiori Property Line SEEPAGE PITS3❑ Depth Size Y - Number- I ' 'SUMPS x r " # ❑ ,Distance to'nearest: Well Foundation "Property Line ' DISPOSAL PONDS Ys ❑ '� I l 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. 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 call for all required inspections. Complete drawing on reverse side. Signed X I/rEl.�.�1. r l.I�� Title:'_ Date: /"17 FOR:D RTMENT UV ONLY J j3 Application Accepted by Date% y Area 07 Pit or Grout Inspection by 1 Date Final Inspection by Date ' Additional Com n s: 4 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Tracy 835-6385 j ,! Applicant - Retur ,allcopies to: Environmental Health Permit/Services 1601 azelton Ave., P.O. Box 2009, Stk., CA 95MI r ` r� / r �- .3 /`( �0 - ��oKY-71 HIT- T+-�u ffvm v, Grp- [✓LZ.S ✓1�sz-.Gt%G' y� S�d7r.e.s7�-2 d+-.'nom v 6L-c.�_d� a.o� 2:�C�...�'c7D+� FEE AMOUNT•DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO (5 U ` : + EH13241REV.t/R5YGibbR ,, , EH W28 V 4 O 0.��