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3: a APPLICATION FOR PERMIT -7 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA i Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED I! x (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. ! �se77o� . ,� Job Address City 3 s y k�'(i Lot Size PM "' Owner's Name - Address g!g 41 Phone 4� +�" Contractor Address �Z - " -IA2 t r' C.7^ License No. Phoney—,,, �# F WELL/PUMP: " NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIOr. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ # . „ OTHER u' DISTANCE TO NEARES . TIC TANK SEWER LINES DISPOSAL FLD..... PROP, LINE FOUNDA __ .AGRICULTURE WELL_ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL7(D AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Manteca a. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type o Specifications ❑ Public ❑ Other ❑ Delta I;t Depthoof Grout`'Sea Type of Grout ❑ Irrigation ;I Approx. Depth 1171 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter 3 Sealing Material {top 50'1 Depth Filler Material (Below 507 TYPE OF SEPTIC WORK: NEW INSTALLATION'p—REPAIR/ADDITION ❑•DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial t yOther ' ' Number of living units: Number of bedrooms, Character of soil to a depth of 3 feet: t l x Water table depth SEPTIC TANK ❑ Type/Mfg '""` Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines "' "" - Total length/size ' k FILTER BED ❑ Distance to nearest: Well Foundation Property Line . SEEPAGE PITS ❑ Depth ;k Size a Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 District. + Home owner or licensed agent's signature cert'rfies,the following: "I ce;fy,that in the erformance 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 following: "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 California." The applicant st call for all r quir tions. Complete drawing on reverse side. 1 s Signed Title: 't" Date: `7 FOR DEPARTMENT USE ONLY Application Accepted by I' Date /— o_ -zo 7 gfea Pit or Grout Inspection by II Date Final Inspection by Date ij Additional Comments: 1s 67 ❑ Stk 466-6781 ❑ Lodi 369-3621 C3 Manteca 823-7104 ❑ Tracy 835-6385 1 Applicant-Return all copies to:: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 FEE l INFO AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY f DATE PERMIT'NO. ? + EH 41REV.1/$s) &� EH 142 � `��` �� ,, ate+ / 1 �'7 50