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;, ,«; �• APPLICATION FOR PERMIT - r�. SAN JOAQUIN LOCAL HEALTH DISTRICT YMENT �1 J - 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 RE(:EIVED PERMIT EXPIRES 1'YEAR FROM DATE ISSUED uN $ 19SS (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereW14V t0P4� L,c44EAtTH I made in compliance with San Joaquin County Ordinance No 549 for sewage or No. 1862 for well/pump and the flutes and�(egula tRW uin Local Health Distract , ;y ' ## ? €i �;t� a ; rtl[MI# Job Address City f. Size PM Owner's Name � � Juyy A1r �t one a Contractor2kt,�u� ,reg, Address Q3.501`5,� icense No. �40�I Phone TYPE OF WELL/PUMP: U NEW WELL D6 WELL REPLACEMENT ❑ DESTRUCTION ❑ L PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.ZZ0 PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS �4�; INTTENDED USE TYPE OF WELL "PROBLEM AREA' CONSTRUCTION SPECIFICATIONS a N I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing XDomestic/Private Gravel Pack L) Tracy Type of Casing V Specifications f I Public Cl Other n Delta Depth of Grout Seal Type of Grou ` I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by dile Repair Work Done LJType of Pump H.P. State Work Done — Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material IBelow 50') r TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION iJ DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.I: Installation will serve: Residence Commercial T Other Number of living units: Number of bedrooms 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 LEACHING LINE ❑ No. & Length of lines Total iengthlsize FILTER BED ❑ Distance to nearest Well _ Foundation Property Line SEEPAGE PITS { I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line ' DISPOSAL PONDS ❑ `- � R I-Hereby certify i'tiat I have prepared this application and that the work inrill 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." t The applicant ust call for all re 'ed inspe ions. ComW,RraD' n on Ta a side. Signed_X! L Date:ARTIVIENT USE ONL ` Application Accepted by J Date /r Area Pit or Grout Inspection by Date Final Inspection by date Additional Comments: 91�0 _ R9 � f� ,; ❑ Stk 466-6781 0 Lodi 369-3621 Manteca 7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO +7 CASH +.EH 13-24 IREV. /y s) de D EH 11-2t1