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APPLICATION FOR PERMIT s � " SAN JOAO.UIN.LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA �d Telephone(209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; to (Complete in Triplicate) oaquin Local Health District for a permit to construct and/or install the work herein described. This application is Application is hereby made to the San J made in compliance with-San Joaquin County Ordinance No.549 for sewage or No. 1862 for weir/pump and the Rules and Regulations of the San Joaquin Local Health District. } - �� '�� -- M� "` .Sy7CJ Lot Size X PM Job Address 2 S` ST City ' Phone Owner's Name-` �v�Ipwt W Ar'K iA1S Address Contractor F w�lD_ Address C._ A)• L-f t-uIA"J AV4 License-No.! � '74 Phone 65� `�� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ l OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL FLD. PROP. LINE WELL OTHER WELL PITS/SUMPS FOUNDATION r AGRICULTURE INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation Dia. of Well Casing ❑ Industrial ❑ Open Bottom El Manteca Type of Casing Specifications [I Domestic/Private ❑ Gravel Pack ❑ Tracy YP _- Type of Grout ❑ Public El Other El Delta Depth of Giout Seal YP ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by H.P. i State WOrk Done— Repair Work Done ❑ Type of Pump Scaling Material'(top 50'1 QA Well Destruction ❑ Well Diameter � g Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR IA-D�DI-TNIO- N`�❑ DESTRUCTION septic itled if pubkic sewer is available within feet 1f J Installation will serve:" Residence Commercial, Other Number of living units: —A-1 Number of bedrooms_4-tR i , Water table depth Character of soil to a depth of 3 feet: A------T No. Compartments (� SEPTIC TANK ❑ Type/Mfg k Capacity` V r -'e`Q I Method of Disposal I PKG. TREATMENT PLT. ❑ . Distance to nearest: ' Well Foundation Property Line e LEACHING LINE 0' No. & Length of lines Total length/size I r Property Line FILTER BED ❑ Distance to nearest: Well Foundation _ r �Cj.- Number SEEPAGE PITS ❑ry Depth Size k SUMPS E] r:Distance to nearest: Well -Foundation ' Property Line DISPOSAL PONDS ❑ I r 4 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. j 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, l signature shall not employ any person in such manner as�to become subject to workman's compensation laws of California." Contractor's Kirin subject to woor �kman1sgompensa certifies the following:"1 certify that in the performance of the work for which this permit is issued,I shall employ pe 1 tion laws of California." The applicant must call for all required inspections._ Complete drawing on reverse side. i Title: - Date: Signed X —:' - FOR DEPARTMENT USE ONLY C� DatMVI AreaApplication Accepted by — .DateT Final Inspection bDatePit or drout Inspection by Additional Comments: ❑ Stk 4&6-Ml ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,-Stk., CA 95201 RECEEVED 8YjDEATE PERMIT'NO. FEE AMOUNT DUE AMOUNT REMITTED CASH , INFO 1 S. ��' TEH13-24(FEV.i/w5) � s EH 14.28 ,_ .y... - •,•�_.» _. .. _