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APPLICATION FOR PERMIT v SAN/JOAO.UIN LOCAL'HEALTH DISTRICT ` l�J 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED" ` ,.+� (Complete in Triplicate) -,t., ,„it.r *.I'+ dl} . r. ,Ar r:t3i2S�ts} 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 i 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. t Size PM City �Jfob Address Y C. `- a Owner's Name f Address - Phone U) Contractor LLAddressZ50 L { License N Phone --TYPE OF'WELLIPL7IVIP�' '�"'"'""�NESI-WELC❑"�'”—"��--WECL REPLACEMENT=❑ DESTRUCTIONS❑ -^J PUMP INSTALLATION,❑ SYSTEM REPAIRC❑ "�} A OTHER ❑ y.} DISTANCE TO NEAREST: SEPTIC TANK PROP. LINE SEWER LINES DISPOSAL FLD. FOUNDATION AGRICULTURE WELL r OTHER,Y ELL PITS/SUMPS INTENDED-USE -_TYP-E-OF-WEL-L—PROBL-EM-AFtEA-�-CONSTRUGTION•-SPEGIFIGATIONS� ',;. �'1 r ! Dia. of Well Casin ❑ Indusfrial , LJ Open Bottom 171 Manteca Dia. of Well Excavation - g ❑ Domestic/Private ❑ Gravel-Pack . ""•,❑ Tracy ,• Type of Casing- L. `�r� Specifications ❑ Public) ❑ Others =Delta- �nepth-of-Grout Seal-�`" �• T r i Type of Grout _ f: ❑ Irrigation f� by pprox. Depth ❑ Eastern Surface Seal Installed , i ' "-r- . "� State Work DorI Repair Work Done El Type of Pump H•P• Sealing Material (top 50'1 Well Destructidn ,. ❑ Well Diameter 9 , f C t t r (Depth I Filler Material-IBelbw 50') � , TYPE OF�SEPTIC-WORK:E NEW INSTALLATION LJREPAIR/ADDITION' .( ESTRUCTION C1 (No septic system'permitted if public sewer is available Within 200 feet.) Installation will serve: Residence commercial— Other # k Number of living units: Number of bedrooms t � I 1 Kbn I I Water taloWdepth Character of soil to a depth of 3 feet. z SEPTIC TANK ❑ TypelMfg f Capacity No. Compartments PKG. TREATMENfPLT,. C] if Method of Disposal s r Distance td crest: Well Foundation _ Property Liine.. LEACHING LINE ❑ No.'& Length of lines k total;length/size tl FILTER BED ` -(C1^fes ''Dstance to nearest: Well Foundation Property Line E '� f # I l i r f SEEPAGE PITS .�6epth i Size, Number SUMPS �" ❑ Distance to nearest:—Well-- -- -- Foundation _ # PProperty Line DISPOSAL PONDS " ❑ I I hereby certify that I have prepared this'application and ihi;A-ihe work will be done in accordance with San Joaquin county ordinances, state laws, and rules and:regulations of the San Joaquin Local Health District. r `� 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 td workman's compensation laws of California."Contractor's 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- wsi of Califo � i t The applic ust call r al equir inspe 6s. mpl to drawing-op)reverse side. Signed Title Date: O i k L I I;— fah l 9� ( AOR DEPARTMENT USE ONLY1 tt 1 i 3 S Area s Application Accepted by Date Pit or Grout Inspection by 21- Date 51-21 FJIL: inal Inspection by `� Date I Additional Comments: �EA ` 17 Stk 466-6781 ❑ Lodo 369-3&1 Manteca 82 n 3-7104 ❑ cy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20 , 09Stk., CA 95201 FEE AMOUNT DUE' "`AMOUNT•REMITTED CASH RECEIVED BY. . DATE PERMIT"NO. INFO + EH 13-24(REV.1(e5) - � "" 4� � 5=tX5EH 1426 A _