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F APPLICATION FOR PERMIT '�-•• SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 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 3:314.5 5 9=_mft�)im City !� Lot Size PM Owner's Name PC)r �� Address Phone Contractor Address license No Phone TYPE OF WELL/PUMP: NEW WELL.❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑. SYSTEM REPAIR ❑ OTHER ❑ 3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL,,—: OTHER WELL PITSISUMPS INTENDED USE TYPE OF WEL0PROBLEM AREA ..CONSTRUCTION SPECIFICATIONS ❑ Industrial ° / '�. ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing. ❑ Domestic/Private <,!„Cl'-Gravel Pack v❑ Tracy --Type-of-Casings Specifications F 1 Public n the�rr � ?'�; r'7 Delta Depth of Grout Seal ° Type of Grout _ I I Irrigation , App h 4Depth i I-Eastern- -. Surface Seal Installed by Repair Work Done ❑ Type of Pump :H.P. State Work Done — Well Destruction ❑ Well Diameters Sealing Material (top 50') 1 Depth Filler Material (Below 50'1 `- TYPE OF SEPTIC WORK: NEW INSTALLATION I.] REPAIR/ADDITION itl;.�-RUCTION l I-(No septic system permitted if public sewer is v" + �y ,, available within 200 feet.) - Installation will serve: Residence t�ommercial 3ther Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: i Water table depth SEPTIC TANK ❑ Type/Mfg M C r t 1�` Capacity d-0 P11 t No. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal I Distance to nearest: We.1k Foundation Property Line LEACHING LINE 1� & Length of lines `~ OT tel length/size A FILTER BED ❑ Distance to nearest: Well Foundation--CLS -- Property Line .-- SEEPAGE PITS NJLrBepth Size &5: Number 1 SUMPS Cl Distance to nearest: Well Foundation S . Property Line DISPOSAL PONDS ❑ E 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, an . rules and regulations of the San Joaquin Locai Health District. a 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."Co'ntractor's hiring of 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- do of California." «� -� The applican t II for requi d-in actions m to drawing on reverse side. r Signe - Title: Date: /�✓ } F R DEPARTMENT,USE ONLY �?• , Application Accepted by C+n� ��c�l1 ,%LJvvXCAANA." Date rArea Pit or Grout Inspection by t Date Final Inspection_by, Date. Additional Comments: t f ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 ❑ Tracy 63. 6385 Applicant Fleurp all capyesto IE 'ronme al Health Per itlServices 1601 Y. Hazelton Av�. Bax 2009, Silk., CA 95241 I FEE 12 )NFO AMOUNT DIE AMOUNT REMITTED CASH _M RECEIVED BY DATE SPP RMIT'N,O. a EH13-24(REV.1 i H 51 -] o .60 EH 14-26 1 V ffff