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F APPLICATION FOR PERMIT V SAN JOA-QUIN LOCAL HEALTH DISTRICT J 1601 E. HAZELTON AVE., STOCKTON, CA ; } Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUE�,•;tnyj;,j�+`j ITi (CompleteinTriplicate) f I#,lrr f Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of 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 n JZT Local Health District �[� r.. - - ffG trjLl( - Job Address ri City Lot Size PM Owner's Name Address 421q ��J p/,.e-�.�[Lr Phone f i 4 -Contractor _ ......A..-dd.r.e..s-�s-....J . 2? / .P..h..o.ne TYPE OF WELL/PUMP: NEVANEI L WELL REPLACEMENT ❑ ESTRUCTION ❑ y µPUMP INSTALLATON ❑ -SYSTEMREPAIRj O HER 0- L' -��OP. LINE^- jy=- 1 - DISTANCE TO NEAREST: SEPTIC TANK IKAILJ�EWER LINES F SP©SAL. LD PR ��',�J[�,, FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j I ENDED USE TYP OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT PN4S industrial pen Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing _ f E❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing—� e Specifications / �•- { f`l Public + r '11'Other I! 1 Delta Depth of Grout Seal ype of Grput - LT- I I I Irrigation1 '—..Approx.-Depth ,;, I Easterri, Surface Seal Installed by _ j � �.-' b� 't R' �k�t t `row - a r Repair Wo* Done ❑-,Type of Pump _ - H.P. '•" State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501! ' TYPE OF SEPTIC WORK: NEW INSTALLATION 111 REPAIR/ADDITION l l/ DESTRUCTION-(-I-ANb septic system permitted if public sewer is 2S " available within 200 feet.( Installation will serve: Residence_ Commercial__ Other Num er of living units: }z Number of bedrooms � +;� Chartacter of soil�o a depth of 3 feet:A Water table depth SEPTIC TANK ❑ Type/Mfg ILI— Capacity No. Compartments t PKG. TREATMENT PLT. ❑ �. Method of Disposal ! Distance to nearest: Well '`)Foundation Property Line j LEACHING LINE ' 0 No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 r -.ece- SEEPAGE PITS I I Depth S12e Number I SUMPS Cl Distance to nearest: Well Foundation Property Line i. I DISPOSAL PONDS ❑ + 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, andt rules and regulations of the San Joaquin Local Health Diltrict. - 4.— 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 ignature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to work ma s compensa- r tion laws of California." r r. t The applicant m ca for all yuire d ctio . Complete drawing on i1se 0 Signed X Is A 21. Ek 4 44L 64 ll, itle: - Date: r `" FO ARTMENT USE ONLY Application Accepted by Data Area k f Pito Gr t Inspection by ate A Final Inspection by Date ; Additional Comments- LI ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83%-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO / AMOUNT DUE AMOUNT REMITTEO CK 4 CASH RECEIVED BY DATE PERMIT'NO. f +.EH 13-24 IREV-i/n 51 00 EH 14-28 —70 ��QS