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APPLICATION FOR PERMIT + ' _• SAN JOAQUIN LOCAL HEALTH DISTRICT z4 2J1601 E. HAZELTON Ar .VE., STOCKTON, CA Telephone (209) 466-6781 ' - . PERMIT EXPIRES .- 1 YEAR FROM DATE ,r/ VIACs rc ti fl,)uz it 1,:jt,.,{ ..tri .(Complete in Triplicate) , , E$:. •�, - ,1 .: 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-complianco Wth 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.idiJi? f ,. Job Address city� .sl�(py Lot Sae //•6 . PM- Owner's �CYNr M Owner's Name Address Phone X37 64S Contractor's Names 144y, O f01� License No. y � -- _ Phone j52-L TYPE OF WELL/PUMP: NEW WELL ❑ WELL^REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Ll DISTANCE TO NEAR EST:ISEPTIC TANK SEINER LINES j DISPOSAL FLD. PROP. LINE 1FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL -` �j i PROBLEM AREA rCONSTRUCTlON SPECIFICATIONS ❑ Industrial ❑Open Bottom'- ❑ M'ante ca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private ❑.GraveLPack ❑ Tracy Type of Casing Specifications ❑ Public E _ + ®-Other ❑ Delta Depth of Grout Seal Type of Grout �❑ Irrigation 1151-'Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done Ll F T- I iof Pump H.P. s State Work Done i Well Destruction ❑ Well.Diameter Sealing Material (top 50') Depth t Filler Material (Below 501 1 1�� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION LJ DESTRUCTION ❑ (NO septic system permitted if public sewer is i } available within 200 feet.) Installation will serve: Residence.X-- Commercial Other Number of living units: f Number of bedrooms +. Character of soil to a depth of 3 feet _ _Water table depth SEPTIC TANK Type/Mfg t 4"r Capacity_060?4 _ No. Compartments " t PKG. TREATMENT PLT. ❑ I { Method of Disposal R t.4 Dis�nce to�nearest: , Well /��' Foundation .ZO'f Property Line dn`LEACHING LINE jrNo. & Lengih of lines A-ev�err: Total length/sizeFILTER BED :❑ Distance ton-darest: Well /.-%V �Foundation 3a y'!' -,Property Line 1: SEEPAGE PITS ❑ Depth r Size Number SUMPS r Wr Distance tomearest: Well /AV Foundation,Id ' :° Property Line 5:'0 DISPOSAL.PONDS. ❑ I herebycern that I have i t pp 'r : q county certify p_'repared this'a lication and that the work will be done in accordance with San Joaquin coon ordinances, state laws, and rules and regulations of the.SamJoaquin Local Health District. f i Home owner or licensedagenYs'.signature certifies the following: 3§ "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such rrianrier as to become subject to workman's compensation laws of California."Contractor s hiring or sub contracting signature certifies the following: "I d`er-tify 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 mu call for all4equired inspections. Complete drawing on reverse side. Y Signed Title: r Date: 1 FOR DEPARTMENT USE ONLY . , - . .� oe Application Acceptea.byr, ¢r t . � _ Datek I Area ; �[7 4— S" �S Pit Or Grout.lhspei tion`'fiy^ -} 1 Date Final Inspection by Date Z ` -Additional Comments: ' Y❑ Stk 466.6781 ❑ Lodi 369-3021 O Manteca 823-7104 r ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 'INFO AMOUNT DUE : AMOUNT REMITTED CK f CASH RECEIVED BY DATE ?ERMiT`NO. f EH 13-241fiEV.10/831 EH 3428 �-