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i a APPLICATION FOR PERMIT } SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E:-HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 1 O NO 1 City oG I of Size_L (1 IPM Owner's Nam,fiqlev Gq r Address Cf Phone Tom— --- Contractor Address License No. Phone --- T PE OF-WELL/.PUMP:. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ s SYSTEM REPAIR ❑ OTHER 0 i� A (STANCE TO NEA EPTIC TANK, SEWER LINES DISPOSAL FLD. PROP. LINE F N AGRICULTURE WELL OTHER WELL PITS/SUMPS _ i, INTENDED USE TYPE OF WELL M AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca. ia.-of Well Excavation Dia. of Well Casing n ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type o Specifications f-I Public ❑ Other ❑ Delta Depth of Grout Sea Type of Grout I f Irrigation �_.Approx. Depth I 1 Eastern_ Surface Sei. installed by _ Repair Work Done ❑ Type of Pump 1H.P. t State Work Done Well Destruction ❑ Well Diameter 'Sealing Material (top 501, Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION i.I .DESTRUCTIO (No septic system permitted if public sewer is { available within 200.feet.) a Q Installation will serve: Residence_.- Commercial—k Other 3 Number of living units: Number of bedrooms s -� ' S Character of soil to a depth of 3 feet: 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 FILTER BED ❑ Distance to nearest: ' Well Foundation Property Line f r SEEPAGE PITS I I Depth Size Number a! _SUMPS- __ .L-7 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 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."Contractors 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 applica t call for all require ins Complete drawingo verse ide.' t Signed X Title: Date: �ORPARThA�NT USE ONLY/ Application Accepted by Date Q off.y T� ea to rs Pit or Grout Inspection b`y�',, �p Date Final Inspection by ate f Additional Comments: 1 bCJL � # / / ,�7 �7r_ �1�� 0 Silk 466-6781 LJ Lodi 369-3621 D Marfteca 823-7104 ❑ Tracy 835-638 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-N0. ��( /J + EH 13-24 IAE5r V.r/x 51 1�_� /i� // ��77�] EH 142e �J °/ / V 'Q f' ./ / I