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' V APPLICATION FOR PERMIT a SAN JOAQUIN LOCAL HEALTH DISTRICT fivi"160 1 E. HAZEL i ON AVE., STOCKTON CA Telephone (209) 466-6781 NOV 5 19,q0 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete In Triplicate) MIT/SERVICES 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. '+ r Job Address City Lot Size PM ' X33 - 5S' Owner's Name Address - D f Phone Contractor L- Address a License No. Phone_ -- _-- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ j SYSTEM"REP,AIfi )K OTHER ❑ SEPTIC T IANK_ SEWER.LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F] Industrial ❑ Open Bottom L1Manteca Dia. of Well Excavation Dia. of Well Casing f 4_� Oomestic/Private ❑ Gravel Pack Cl Tracy I Type of Casing Specifications 'I'1 Public F Other ❑ Delta ! Depth of Grout Seal Type of Grout- ) rout ')Irrigation °.Approx. Depth l I Eastern Surface Seal Installed by _ I Repair Work Done ❑ Type of Pump / H.P. State Work Done kWell Destruction' ❑ Well°Diameter _..... _ Sealing Material Itop 501 r Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION i 1 DESTRUCTION ! I (No septic system permifted,tif public sewer is 15I � available within 200 feet.) j k Installation will serve: Residence Commercial"_E Other Number of livingiunits: Number of bedrooms j Character of soil to a depth�6r 3 feet: Water : Ytable depth.. SEPTIC TANK `TY4'pPelMf !' Capacity No. Compartments PKG. TREATMENT PLT. ❑ J`h Method of Disposal Distance to nearest: Well y Foundation Property Line i � � LEACHING LINE LI\ No. & Length of linesj Total length/size -� FILTER BED O--Distance to nearest: Well I ��' Foundation Property Line 'T SEEPAGE I f f SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line IN DISPOSAL PONDS ❑ 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 Di%trict. 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, 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-contracting signature ` certifies the follo : "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Ii or ia." 11 1 The apt t m t call for all r fired inspe ins. Complete drawing on rev r side. Signed X Title: Date: FOR DEPARTMENT USE ONLY7 Application Accepted by0W Date 7.-�� Area I J li r 'y Pit or Grout Inspection by Date Final Inspection byDate/ .y Additional Comments: ❑-Stk 466,6781--—LJ-Lodi,w.369-3621=---- 11-Manteca- 823-7104—❑ Tracy-835-6385- Applicant 35-6385-Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ,' .T ✓-..'A J �f�'i�v� �. -tet� ' y �, w INFOEANT DUE" -AMOUNT REMITTED" ASH CK RECEIVED BY - DATE PERthlll7 NO w I ..EH 13-21[REV.1 i y SI EH 14-2e 6/V