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it ! a APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,:STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y p -.,,,#„-.(Complete in Triplicate)_ i'.�; .: `” n may. 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 Disfrict.' I t f fiF7a f Ji,' Job Address / 02 ! )�"'�g' ce City `' 7<4 Lot1Size - PM ' W9 ergs`Na Contractor L1d1d►.P Address Y License No. Phone TYPE OF WELL/PUMP: !� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ F PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑Domestic/Private ❑ Ghavel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 1;2 ❑ Irrigation_ pprox.,Depth .—CI-Eastern-^ Surface Seal'Installed by Repair Work Done ❑ Type i of Pump H.P. State Work Dane Well Destruction ❑ Well:Diameter Sealing Material {top 501 ` ! Depth Filler Material (Below 501 z �� TYPE OF SEPTIC WORK; NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRU ION No sep c system permitted if public sewer is d T i _ a ilabl within 200'feet.) C .. Installation will serve: Residence o Commercial Other : Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: - Water table depth PKG. TREATMENT PLT. p Type/Mfg. ^� _ ..�r Capacity�--- '`"" No. Compartments SEPTIC TANK ❑ T - _ ` Method of Disposal' fDistance to nearest: WellFoundation Property Line I ,IJk LEACHING LINE ❑` No. & Length of lines A Total length/size r }. FILTER BED"' ❑ Distance to nearest: Well -Foundation Property Line i 41 SEEPAGE PITS dDepth Size --- Nufrlber SUMPS ❑. Dristance to nearest: Well_` - Foundation Proper, DISPOSAL PONDS 1:1II ti Z j t — I hereby certify that I have prepared this application and that the work will be done in accordance with SarrJoaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health.District: - . .r -, r ` Home owner er or.licensed a ent s si nature certifies the fallawin :.':l certify that in the rformance f h 9 9 9 Y pe o the work for which this permit is issued I shall not w employ any person in such,riianner as.to.becdme 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." 1 The ap i ant must c II for all required inspections. Complete drawing on reverse side. Sign d I! Title: Date. 3� F EPARTM T USE ONLY Application Accepted by Date 3 Area v Pit or Grout Inspection by ate Final inspection b Date 2 Additional Comments: f (off f�'6�- ❑ Stk 466-6781 ❑ Lodi., -3621 ❑ Manteca 823-7104 O Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IF 0 AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. + EH'13-241REV.rfa5) /`I/` f ' F 5H 14-28 ) - �* 00 ��-4 % ,/� �`7 n .