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_ APPLICATION FOR PERMIT �! , SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA '941V Telephone (209) 466-6781 &,6, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 47-1yp(Jffv I (Complete in Triplicate) fain �' 6 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.7t1s appli cation is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules a dra'R,e�glations of San Jeaqu' Local Health District. : r 'z/�iGlC City /J .—� Lot Size k PM Job AddressIh A57-. Phone Owner's Name 'I - Address _ 1 d��_._ Phone -!-7-1 1 Contractors name 'ter I_. S 'License No. TYPE OF ELL/PUMP: NEW WELL El SYSTEM REPLACEMENT ❑ DESTRUCTION 11 PUMP INSTALLATION L1SYSTEM REPAIR F1 OTHER ❑ rDISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC_TANK SEWER LINES l 1' t t.j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE`OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS? pia. of Well asing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ , - Type of Casing— j Spec icatfbns� {y '1, ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T of Grout I Ll Public Ll Other ❑ Delta Depth of Grout Seal `Type ❑ Irrigation l Other x. Depth ❑ Eastern Surface Seal installed by I H.P. State_ Work Done Repair Work Done ❑ Type of Pumpt N Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 50'} TYPE OF SEPTIC WORK: NEW INSTALLATION RE ON ❑ DESTRUCTION .evailabNo pe1withine200 feet.) public sewer is n Installation will serve: Residence_X_ Commercial— Other x i Number of living units: —/— Number of bedrooms n L Watertable depth Character of soil to a depth of 3 feet: ' ' w': No. Comps ments Type/Mf t �S fi, Capacity SEPTIC TANK g .4 ' ' _ Method of-Dlspolial_ PKG. TREATMENT PLT. ❑ 1 ;i '" Property Line 4 Distance to,nearest: Well, Fa .= Foundation V No & Length of line's Totpl leng'thlsiz- ' LEACHING LINE ,._ �, i, 9 , , Property Line FILTER BED ❑ Distance to nearest: Well,/�� Foundation HSEEPAGE PITS Depth Size u"' um ❑ Distance to nearest: Well Found-tion T Property j77Li SUMPS i no DISPOSAL PONDS ❑ I hereby certify that l 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. I ure certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person licensed in such manner agent's signat atto become subject to workman's compensation laws of California."Contractor .....� Contractor's hiring or sub-contracting sigaturR Home owner or �the work for which this permit is issued,I shall employ persons subject to workman's compensa- certifies the following: certify that in the performance of tion laws of California." The applicant mus c for all requir d inspections. Complete drawing on reverse side. Q Title: Date: Signed FOR DEPART ENT USE ONLY C� Area Application 1 ` Date� Application Accepted by i /L��{ o- Final inspection b - Date Pit or-Grout Inspection by Date_�� Additionnaa(Comments: 835-6385 ' T ❑ Stk 466-6781 ] Lodi 369 3621 ❑-Manteca 823-7104 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1$01 E. Hazelton Ave., P.O. Box 2009, Stk. CA 95201 ' vf+Y- •h � I 1 � .� .. MPERMITFEE CASHRECEI VED 8Y DATE INFO4AIIAOUNT DUE AMOUNT REMITTED+ EH0!831 .�.�,:•�-�.,..