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APPLICATION FOR PERMIT fvow µ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA I, Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Inn Ill (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. 3 Job Address 5-2- City �� Lot Size PM Owner's Name C/ �1 A/6"'" e"'?M�Address � �^ Phone Contractor Address �7"v' C�` /?'License No. roa'rT-�' Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 171 SYSTEM REPAIR ❑ OTHER ❑ biSTAJCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.- k PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL-t PITS/SUMPS INT NDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ❑ Industrial LJ'Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 18 Gravel Pack ❑ Tracy-- Type of Casing i Specifications M Publiie HCl Other. ❑ Delta Depth of Grout Seal i Type of Grout _ I I Irrigation —_APPXq?m P_f!Pt_h I11 stern Surface Seal Installed by _ Repair Work Done ❑. Type Of Pump �.! H.P. State Work Done Well Destruction O Well Diameter Sealing Material Itop 50'f --Depth Filler Material (Below 501 'V TYPE OIF SEPTIC WORK: PINSTALLATION I') REPAIWADDITION i I DESTRUCTIO o Nseptic system permitted if public sewer is 444 available withiri 200 feet.) Installation will serye: RPEW dence_ Commercial_ Other Number of living units: Number of bedrooms Charaf ter of soil to a depth of 3'feet:;• + �s Water table epth SEPTICiTANK ElType/Mf6%', Capacity No. Compartments PKG, TREATMEN� PLT. ❑ Method 6f Disposal Distance 4o.nearer' Well Foundation Property Line f LEACHING LINE ❑ No. & Length of lines }} g Total left th/size FILTER BED -4—(5—Distance-to-.nearest:"'—Well Foundation Pro rty Line SEEPAdE PITS I 1 Depth Size . Number i SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r' ? I hereby certify that I have prepared this application and that theworkwill be done"in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. . ' 1 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 ny person in such manner as to become subject to workman's compensation laws of California." Corft-ractor`s hiring or sub-contracting signature certifies the following: ';Iiertify that in the performance of the work for which thisperrnit is issued, I shall employ persons subject to workman's compensa- tion law of Californi The applicant mu II P3WITeAjOactions. Complete drawing on�reverse `side. t _..._.,.-�... Signe ��;__._._._.-.._..._-....,.....-__. ,..._.-�.._-..-.-.._Title: __.._(`��T �� +.......,,,..----_._. � Date: A "EPARTMENT USE ONLY Application Accepted b 4a. ��„Ch�.�s--. �} Date Area Pit or Grout Inspection by Date Final Inspection by ] Date L5 Additional Comments: I'LL L V k- .4—d ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INF OUNT DUE AMOUNT REMITTED ASH CK 4 RECEIVED BY DATE PERMIT'NO. 0 a.EH 13-�-28 24IREV.tin 51 356 : � An/ lG4 1,PS�-113.5- EH 1