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it APP,,/. CANON FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 'i 1601 E. HAZEL T ON AVE., STOCKTON, CA ' Telephone"(209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . (Complete in Triplicate)}, C�7 of ,fie c Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.TMs ap lication is made in compliance with San Joaquin County Ordinance No.549for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health'District. Joh Address �L/ . r: ; City • W_"Lot Size�1� ►r` PM Owner's NameAddress �� i 'T Phone ContractorL LT ddress V License NO w _ Phone " STYPE OF WELL/PUMP: i�' 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'v=�YPE-OF-WEEL"'PROBLEM R"AEA " STRl'JC FDW§PECIFICATI(MS ' ❑ Industrial t ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack - ❑ Tracy Type of Casing Specifications k ❑ Public # ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by1F Repair Work Done ❑ Type h of Pump H.P. State Work Done_ p� Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth" ^-,Filler-Material-(Below 50')_ TYPE OF SEPTIC WORK: NEV1f INSTALLATION ❑ REPAIR/ADDITION ESTRUCTION ❑ INo septic system permitted if public sewer is 4available within 200 feet.) Installation~will serve: Res'd�ence_-L---Commercial:'�t Other: Number of living units: IM Number of bedrooms Character of soil to a depth of feet: � -Water:idble depth U SEPTIC TANK ❑ Tlype/Mfg Capacity 1 No. Compartments PKG- TREA I ENT,PLT. ❑ it F" ® I ;Method of Disposal j Distance to neare t: Well Fo ndation Property Line ---- - - LEACHING LINE Mg N-,. & Length of'lines T?tal length/size. FILTER BED ❑ Distance to nearest: Well Foundation /D �4 Property Line SEEPAGE PITS Depth Size Number ` SUMPS ❑ Distance to nearest: Well Foundation 3 Property'Lme DISPOSAL PONDS ❑ hereby certijy that I have prepared this application and that the work will be done in accordance with"San Joaquin courity ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. *' Home ownerIor licensed agents signature certifies the following: "I certify that in the performance of the-Work for which this permit is issued, 1 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 certifie the fdllowing: "I certify that in the performance of the work for which this permit is issued,I,shall employ persons subject to workman's conipensa- tion laws aiiforni ;� E Th applican st call r a I equi d ins io . Complete drawing onn pverse si e. l J w � f Signed Title:" Date: f N FOR DEPART TI$ ONLY /" ' Application Accepted by Date��l+r/ / '� rea / x. I +. ' Pit or Grout I spection by 4 "` Date Final Inspection by Date �l F Additional Comments: ❑ Stk 466-1781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385 - Applicant- Rbturn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.; P.0.-Box 2009, Stk., CA 95201 FEE INFO AMQUNT DUE AMOUNT REMITTED DK RECEIVED BY PATE PERMIT NO. CASTI a EH 13.24I REV.tiasl' 1 � a : . EH 14-28i �I ...�., T / " +,%A-7 tE III"