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APPLICATION FOR PERMIT - ( �! r � /111 ,ts • SAN JOAQUIN LOCAL HEALTH DISTRICT. t4 1601 E. HAZE T ON 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. Job Address, City Lot Size PM � T � i „". Owner's Name ddress 3' tela fir' .cB t( �7 ca, .--,-- Phon�Ye- Ar Contractor 1444 ddressZIT File? License No� - �_Phone �.�O-S ,TYPE OF WELL/PUMP: NEW. ELL WELL R ACEMENT ❑ DESTRUCTION ❑ ry PUMP INSTALLATION, GRO� SYSTEM REPAIR © OTHER ❑ _ DISTANCE TO NEAREST; SEPTIC TANK +�� SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 20_� AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE- TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_/ZFI Dia. of Well Casing r� Jebomeslic/Private LeG"avel"Pack " ❑ Tracy Type of Casing _ e e _ Specifications 94 lI Public ❑ Other F3 Delta Depth of Grout Seal of f i!22 Type of Grout 6t_I Irrigation .Appfox. Depth I I Eastern Surface Seal Installed by Repair Work' Done. El 'Type of Pump H.P. State Work Done Well Destruction ❑ WellDiametera"'o Sealing Material {top 501 Depth Filler Material (Below 501 7 00 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 ) REPAIR/ADDITION I I DESTRUCTION ( I (No septic system permitted if public sewer is available within 200 feet.) installation will serve: Residence_ Commercial_ Other { Number of.living units: _ Number of bedrooms f j Character of soil tosa depth of 3 feet: Water table depth SEPTIC TANK J" ❑ T e/Mf x t Yp 9 Capacity No. Compartments T PKG. TREATMENT PLT. ❑ Method'of disposal Distance to nearest: Well Foundation Property Line LEACHING LINE" ❑ No. & L`ength of lines Total length/size +, FILTER BED i ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i 1 Depth Size Number _ SUMPS Ll Distance to nearest: Well" Foundation Property Line DISPOSAL PONDS . ❑ 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. A 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 followin :"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- •� tiori laws of Califo The applicant m st call f r all requir inspec ions. Complete drawing on re r e side. Signed X d Title: a.� Date DEPARTMENT USE ONLY II 7� 1� Application Accepted by pate ��t) ll_ Area Q Pit or 6. t Inspection by Data _ G Final Inspection by Gu-r/Date r Additional Comments: , Stk 466-6781'-, ❑ Lodi 369-3621 ❑ Manteca 523-7104 El Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t 41 FEE AMOUNT DUE �AM�OUNTREMITTED CKRECEIVED BY /?ATE PERMIT'NO. EH INFO 1p �'�S� L'` �,-flCASHHI 1-RE 1LF l+ EH 3.2414�tREV.r i x sl t! e�/V l(.J J��~ r I / C �'�-/�J 3�1 O '�O -r 1 qp aa1