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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEI_TON AVE., STOCKTON, CA Telephone (209) 466-6781 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. -7- Job Address ?�klo®� + tr'� �� City Lot Size PM Owner's Name I'EtAddress f Phone aI S�� Contractor IN L.TII� �.L-.Address s License No. 3 0 YA Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL-REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION -AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL? # PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public l] Other ❑ Delta Depth of Grout Seal Type of Grout r ❑•Irrigation. --Approx. Depth E Eastern Surface Seal Installed by Repair Work,Done El Type of Pump` H.P. State Work Done Well Destruction -❑ Well'Diameter Sealing Material {top 501 v e Depth Filler''Material (Below 501 �Q TYPE OF SEPTIC-WORK:_NEW-INSTALLATION �REPAIRIADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is :"-, available within 200 feet.) Installation will serve: Resid nce �Commerc6-17 11--OtH& -- ' y Number of living units: Number of becir ms Character of soil tc a'depth cif 3 feeit: Water table depth SEPTIC TANK 1--Type/Mfg i 5 Capacity No. Compartments PKG. TREATMENT PLT. ❑i_ i ► Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ®.—Ade. & Length of lines Total length/size l FILTER BED ❑- Distance to nearest: Well �Rn Foundation d Property Line }? ` 3 3 : de SEEPAGE PITS 33— pth _r� -Size 3 �NvNumberLmftmd— �, � SUMPS F1 Distance to nearest: Well- Foundat . Property Line__!_.v-sem7 DISPOSAL PONDS ❑ 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:'� k NV 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�subjedto workman's compensation taws of California." Contractor's hiring or sub-contracting signature certifi a following: "I rtify that in the orrriance of the work for which this permit is issued,i shall employ persons subject to workman's compensa- tion laws o liforn1a." Th applican mu call for all equi d ins tions. m e drawing on r verse sicL6. Signed F Title: Date: r � � OR iDEPARTMEN USE ONLY Application Accepted by V V Date �� Area 44 Pit or Grout Inspection by Data Final Inspection by Date aJb Additional Comments: % ElStk 466-6781 Lodi 1 ❑ Manteca 104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1-' FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT`NO, INFO CASH ?�'c. aEH 13-24(R V/B5) 0.� S-775 W q/64 ff / r/9 11 Ey 1428 II :^z.