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APPLICATION FOR PERMIT _ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 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 Owner's Name &A 4 Address Z99 Phone Contractor ,Address License No. Y alz4Phone �*�'+/0V TYPE OFWELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER,EINES DISPOSAL FLD. PROP. LINE r F'. Y FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLIEWAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca w;� Dia. of`Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications' r'l Public Ll Other i l Delta Depth of Grout Seal Type of Grout I I Irrigation _.-Appmx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H,P. Stat'e Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'), t Depth Filler Material /Below 501 • TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION l 17 DESTRUCTIONAd Wo septic system permitted it public sewer is J7 r available within 200 feet.) 09a Installation will serve: "Residence X-1 Commercial— 'Other Number of living units: _� Number of bedrooms IF _.. r Character of soil to a depth of 3 feet: "? f Water table,depth SEPTIC TANK fA Type/Mfg- Capacity No. Compartments r PKG. TREATMENT PLT. CJ- �*< r >� i '� Method of Disposal r s f' ,`"Distance to nearest: Well Foundation Property.Line LEACHING LINE No. & Length of lines r Total length/size d x FILTER BED ❑ Distance to nearest: Well -Fours dation 1 T'-F Property Line r SEEPAGE PITS I I Depth JU' Size l = -.,Number SUMP Ll Distance to nearest- WellIni� +ounclation / " ' Property Line_? r� DISPOSAL PONDS -❑" ' / r 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. Home owner or licensed agent's signature certifies the fdllouiind:;'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-tionf'acbrig signature certifies the following: "I certify that in the performance of the work for which this permit is issued,t'shall employ persons subject to workman's compensa- tion laws of Californ' f p The applicant c�a/ll/for�a1I requi ctions. Complete drawing on reverse side. - F Signed X // ''�"" Title: �il�� baie:'f' /17 FOR DEPARTMENT.USE ONLY Application Accepted by Date Area Pit or Grout Inspection byDate Final Inspection by 4AK 48&n Date �� Additional Comments: f4J44 amu'TZff f� (4 )11-e Of eW v 1'T`►�"' f L ''^ f O Stk 466-6791 ❑ Lodi 369-3621 .❑ Manteca 823-7104 O Tracy 835-6385 e i ee Applicant - Return all copies to:,Environmental Health Permit/Services,1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4.017 FEE INFO AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMIVNO-- -T- .' _ +. H 13-24/REV.1'y X 51 t�O EH 14-29 � E �