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APPLICATION FOR PERMIT t. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,.STOCKTCIN, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED s x f (Complete.in Triplicate) ,,._ ..; t 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 Ai';�i�.liG.rp /C �l ` s R C. 4st¢1Lf�7s�e � Lot Sizey` pryT Owner's NameQ �•'~h�GfJ/��-_ Address �6 �� Phone Contractor '+~Address ✓ ' `�\ License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ <,WELL REPLACEMENT-❑ -j, y' DESTRUCTION ❑ PUMP INSTALLATION ❑. -REPAIR-0OTHER❑ J' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED US TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS' ❑ lndusfrZl ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing O Domestic/Private ❑ Gravel Pack ❑ Trac T ; Y Type of Casing Specifcations 'n Public ❑ Other Cl Delta 1413el5th 0 G o t Seal Type of Grout 71 �]r� 1 Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by �� y ,.Rcpair Work Done : ❑ Type of Pump H.P. State Work Done_ Well Destruction r❑ Well Diameter ^- 'Sealing bilaterial{top 50'I Depth Filler Material [Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION+ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms ` Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK LlTe/Mf + � € Type/Mfg _ Capacit No. Compartments PKG. TREATMENT PLT. ❑ �,. r� € Method of Disposal Distance to nearest: Well-...- Foundation , Property Line LEACHING LINE ^ ❑ No. & Length of lines •� Total length/size t FILTER BED ❑ Distance to nearest: Well a` Foundation I I Property Liner l SEEPAGE PITS ❑ Depth I Size f Number SUMPS LlDistance to nearest: Well Foundation Property Line ` DISPOSAL PONDS ❑ I hereby certify that ! have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I .rules and regulations of the San Joaquin Local Health.District. 1 Home 6Wner or licensed agent's signature certifies the following. ;;l certify that in 'performance of the work for which this permit is issued, I shall not employ ally person in such manner as to become sublet[to workman's compensation.laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that-in theperformance of the work far which this permit is-issued,I shall employ persons subject to workman's compensa tion laws of California." ` The applican us call for all r 'red Spec tio Complete drawing on reverse side. g t I �1 Signed X Title: I Date: S F R DEPARTMENT USE 0111LY Application Accepted by %Date y ' r4- ere r ,P? - Area ; i Pit or Grout Inspection b t ' r J 7�2 Pe Y Date Final Inspection,by Date {{ F r Additional Comments: t r f } ❑ Stk 466-6701 0 Lodi 369-3621 € fl Manteca 823-7104 i3 Tracy 835-6385 { " Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.0 YBox 2000, Stk., CA 95201 FEE INFO AMpUNT. DUE MO<jNT-REMIT ffp w �- - H,n�:= RECEIVED BYE""'`—"-t)AfE PERMIT ND. + EH i3-24 IHEV.t i R s) "�/'1 O 0 f -7 - 1 �`--- (/_}�� S EH 14-26- (// f5 4�?5�+ �\ �� 53.x.. I