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r . . APPLICATION FOR PERMIT p SAN JOAQUIN LOCAL HEALTH DISTRICT 5 J 1601 E. HAZELTON AVE.,—STOCKTON, CA Telephone (209) 466-6781 NO -IA i PERMIT EXPIRES 1 YEAR FROM DATE}ISSUED .., t-r • , .._{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 District74.' ' tJ. Job Addressr Cit ` - :2, �Y Lot Size PM Ow e! Name - Address'—��o+ m•/2, �t/1�tlJ — Phone �1 d AyJ10 �ense No. C7 Contractor ddress ��phone TYPE OF WELL/PUMP: ;NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 1-1 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEA PTIC TANK _ _SE:WER_LIN_ES _ _ DISPOSAL FLD. _1 PROPVLINE FOUNDATI n T AGRICULTURE,WELL OTHER WELL SPITS/SU14AP5 {� _ . . - r l INTENDED USE TYPE OF;WELL J PROB REk� COiVSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom CI_Manteca carocavation—'�r g` Dia(le -of.Weil Casing` El Domestic/Private Gravel Pack Tracy Type of Casing Specifications ❑ Public ❑ Other __.❑ Delta Depth of Grout Seal pe of Grout ❑ Irrigation �Apprgx-. Depth„�Q_Eastern•,_, ..Surface Seal-installed.by -- Repair Work Done ❑ Type of Pump H. State Work Done Well Destruction ❑ Well Diameter Sealing Material (tdp Depth; Fillhr Material fSelow 50'y' t TYPE OF SEPTIC WORK: NEW;INSTALLATION ❑ REPAIR/ADDITION Q DESTRUCT10 (No septic system_parmitted if public sewer is i t it i-M available within 200''feet ) Installation will-serve: Residence . Commercial— Other 7 Number of livingiunits: .� -1, Number of bedrooms i . Character of soil to a depth of feet: i Water table depth r SEPTIC TANK ❑ Type/Mfg ) i _ § Capacity No. Compartments PKG. TREATMENT PLT- ❑ - Method of Disposal �. t Distance to nearest: - Well Foundation Property Line LEACHING LIfE`' ti- ❑'No'& Length of lines — t i 'r' g Total length/size q. i _ ._ :,�;?7� 1�, FILTER BED ❑ Distance to nearest: Well I j r foundation Property Line SEEPAGE PITS "' ❑¢ Depth t p ` Size .it r Number r- - SUMPS ❑_ Distance to nearest: Well- ! -- Foundation Property Line �. DISPOSAL PONDS] _ ❑ t ` •p f � I hereby certify that I have prepared this application and that the work will'be done in accordance with San Joaquin c unty ordinances, state laws, and ( _ rules and regulations of the San Joaquin Local Health District. . _ ' -i, r -�• I• F: I—...x 1 to "7 t Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for whic this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California.:=Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which thise'rmit is issued, I shall employ ! p p y personstfsubject to workman's compensa- tion laws of California." # J } R The applicant must for all equire spections. Complete drawing on reverse-side. f; Signe Title: ate: a,l r R DEPARTMENT.USE ONLY { Application Accepted by Date' T� Area Pit or Grout Inspection by g Date Final Inspection by '_' Date 3� J ! Additional Comments: � y- ya ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104_ ❑ Tracy 835-6385 t t 3 Applicant- Return all copies to: Environmental Health Permit/Services 1601,E. Hazelton'iA e., P.O-Bax 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY GATE PERMIT'NO. + EH13-24 IREV.11 k sl 3��'• CSC-) ] 5 r� "