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APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICTV�� 1601 E. HAZEL T ON AVE. StTOCKTON, CA Telephone (209)f466-6781 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.-11862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address %,v VLA- j. ''aa City . 0o N Lot Size O Z. PM Owner's Name L.Jc VVL Address "'..4d. Phone 77 Contractor, Address License No. Phone TYPE OF WELL/PUMP:, NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Y PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ _DISTANCE TONEARSEPTIC TANK SEWER LINES DISPOSAL FLD. ROP. LINE FO AGRICULTURE WELL t OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF�WELL PRO A CONSTRUEtION SPECIFIC (DNS - ❑ Industrial ❑ Open Bottom ❑ Manteca e f�l xcavation ❑ Domestic/Private 17_Gravel Pack Dia. of Well Casing .. ...._r. ,...__ '_._� ._ v Type of Ca:in Specifications fl Public Fl Othe l❑ Delta Depth of Grout Seal �< �- "' t__.. _ i p v Type of Grout I-i.Irrigation• -±- Approx. Depth•, •-I i East. _Surface=Seal"'Installed-.by- .' Repair Work D ❑ Type of Pump H.P. State Work Done Wen Destr itic ion ❑^ Well DiameterSealing Material (top 50'1 r -.._Depthi .. +. - Filler Material fBelaw�50'1 t TYPE OF SEPTIC WORK NEW INSTALLATION 1.1 REPAIR/ADDITION I 1 DESTRUCTIO I (No septic system permitted if public sewer is ~ vailabre within 200 feet'.) _ fitstanat�on will serve: Residerice Commercial_ Other Number of;living units: Number of bedrooms .-- R• """' `Character's I-soil to-a depth of 3 feet: Water table depth -- _ SEPTIC TANK O,_•Type/Mf No, Compartments 9. Capacity + PKG. TREATMENT PLT. ❑, ' ' T. � Disposal Disnce to neare -st- Well' Foundation� Property L ned of bi ❑ Distance to nearest: Wen- - � Total lenfoperze LEACHING !._,INE ❑' No. & Length of lines I E TER BED,.._. .._:, " - d �.n .__ _ u ' -.;Foun�alio __ -Pr Line operty FILTER SEEPAGE PITS I I= Depth Size e Number _ SUMPS "°'"`- ❑.- Distance'to'nearest:- Well� ' foundation - � t- Propertyt - _ n 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. ! Ho'me owner'or licensed agents 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 compensatioriYlaws of California." Contractor's hiking 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.law's of California."�---_ .____, p - •__ 48 ) r The applicant t call for all r ulred ins , } y g on reverse side. q inspections. Complete drawing Signed X f '- . Date: FOR DEPARTMENT USE ONLY c j Application Accepted 6y - t Date Area " _ max,.. ,.• --. Vin . .. .. -* ...o.• __.. t Pit or Grout Inspectio y Date F1'Inspection'b _ Da inay te Additional Comments: ❑ Stk '466 6781 ❑Lodi 369-3621., - ❑ Manteca• 823:7104 1'4 ❑Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601E Hazelton Ave., P.O. Box 2009, Stk.,'CA 95201 - -a -.FEE ;. AMOUNT DUE ._ AMOUNT REMITTED -•- t INFO CASH RECEIVED BY - DATE PERMIT'ND. ♦.EH 73-24EV."in �,� s) -S -._. _. � p•-•�� ff�;�q.,5� ....�...o EH 14-2e 1R . o P � l