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rr- APPLICATION',FOR PERMIT s SAN JOAQUIN LOCAL HEALTH DISTRICT p AG 5_0 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 t '� i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 'II (Complete in Triplicate) Application is hereby made tolthe San Joaquin Local Health District for a permit to construct and/or install the work her elrt des�S RM9Tt�SS Mi&On is made in compliance with Sari'.oaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin t Local Health District. �9, f dress �`' lYI J'B 1 , �Q JI�I"J!�D [l�? 4r� 7 City t i Job Ad /� j •Q� Lot Size v e � PM Owner's Name 0�7.._ A /� ee19. Address 'z Qs 16A �`� ® C�9`s` Phone(Zp 9 S �z�1 _ Contractor L cur es fL�/q/t! Address 7 ® JM,/ License No. 33�►t'7d� Phone 2 -`�Q TYPE OF WELL/PUMP_ ii�; NEW WELL LJ WELL REPLACEMENT 11 DESTRUCTION 171PUMP INSTALLATION F1SYSTEM REPAIR ❑ OTHER ❑ U� DISTANCE TO NEAREST:.SEPTIC TANKr SEWER LINES DISPOSAL FLD. PROP. LINE k F6UN6ATION'__AGRICULTURE WELL OTHER SHELL—'PITS/SUMPS PITSISl1MPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l ❑ Industrial 0"Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 0.Gravel Pack ❑ Tracy Type of Casing Specifications [`l Publicn, Other Cl Delta Depth of Grout Seal Type of Grout r I I Irrigation ��M Approx. Depth I I Eastern Surface Seal Installed W6_1 - i „, Repair Work Done ❑ Type of Pump H.P. State Work Done V1 Well Destruction Cl Well Diameter Sealing Material (top 501 Depth . Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION [:I REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other U Number of living units: Number of bedrooms , Character of soil to a dep[h of 3 feet: Water table depth i SEPTIC TANK ❑ I Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. 11i Method of Disposal Distance to nearest: Well Foundation Property Line t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line V SEEPAGE PITS 1 1! Depth Size Number i SUMPS ❑ Distance to nearest: Well Foundation Property tine DISPOSAL PONDS ❑I - ' 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 I rules and regulations of the San Joaquin Local Health District. r 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." Contractoes hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,k shall employ parsons ensa- subjsubject to workman's com P tion laws of California." The applicant• st call for.all a ad inspections. Complete drawing on verse side. Signed X I Title: Date: 9 FOR DEPARTMENT USE ONLY Application Accepted by 9991 Date Are Pit or Grout Inspection by Dated Final Inspection by], zi date F Additional Comments: I ❑ Stk 466-6781 ❑ L`odi 369-3621 ❑ Manteca B23 7104 b Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4 FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO .r + EH 13-241RE1.1rr551S. EH 1429 Ar