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4 P APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA i i Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED *ac ICOMplete 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.= Q. Job Address S��IV City c Lot Size 9SX Ael! PM Owner's Name D Ad Address Phone Contractor F'LQ W&D Address &U SC- AL e, LI 1—Ur4AJ License No.46�fC2.74 Phone.6/6 -3,7-7i TYPE OF WELL/PUMP: i NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ - OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER}LINES DISPOSAL FL'D. 'PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL �N PITS/SUMPS y,s INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i, ❑ Industrial ❑ Open Bottom ❑ Manteca') '0ia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private D Gravel Pack ❑ Tracy ; Type of Casing Specifications ❑ Public ❑ Other t#€ 1-1Delta fz' Depth of Grout Seal Type of Grout� ❑ irrigation a --::�4pprox-Depth ❑-Eastern-^ r fSurface-Seal InstaHetl Repair Work Done ❑ Type,of Pump H.P. State Work Done-.- �J y : Well Destruction B Well',Diameter Sealing.Material (top 501 Depth' ' Filler Material (Below 501 'f TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted,if;public sewer is ,tell d; available within 20D'feet.) Installation will serve: Residence Commercial_ Other s ,•� Number of living units: L.,i Number of bedrooms.._ .....— I Character of soil to a depthh f 3 feet: r,(.4•V - Water table depth SEPTIC TANK - Type/Mfg �L�f+ _ Capacity f rd!C2 No. Compartments PKG. TREATMENT PLT. ❑ tk �` Method of pisposal Distance to nearest: Well S7 Foundation _-_- Property Line ZSR LEACHING LINE 111Ndr. & Length of lines ��Q f Total length/size `X Z J `! FILTER BED Cl Distance to nearest: Well_ Foundation �®D Property Line j SEEPAGE PITS Depth a.� Size 3 _ Number SUMPS Cl Distance to nearest: Well `77 a Foundation 7��d Property Line 2 ; DISPOSAL PONDS C3 X I hereby certify that I have prepared this application and that the wdrk will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I Home owner or licensed agent's�si nature certifies the following:g: "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."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." ' 3 � The applicant must ca for all quired inspectio Complete drawing bn reverse side. ! Signed = Title: Y __- Date: et ! FOR DEPARTMENT USE ONLY Application Accepts by � "` Date `e� Area it Grout Inspect) by Date'Final Inspection by' DateL�. Additional Comments: ❑ 5tk 46&6781 ❑ LodiI; 369-3621 .0 Manteca 823-7104- '0 Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2DD9, Stk., CA 95241 CK FEE INFO AMOUNT DUE AMOUNT'REMITTED— `'``CASH RECEIVED BY DATE PERMIT'NO. + EH 13.21(REV.I/851 ' it - "L I' - 1 �4 EH 1428 0 1 '� + �{ S] - J y. /� T_