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h^s"*Fi r,f V-P APPLICATION FOR PERMIT iefrll,tJ i Cf/�►"` hu SAN JOAQUIN LOCAL HEALTH DISTRICT o>r{ + 53 rt{ I lrq fy-w-4• 1601 E. HAZELTON AVE., STOCKTON, CA welt dr:�itry i.� j ✓fie J' Telephone (209) 466-6781 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. 1$62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address - b i / Ife City (:56Co6hrJx.l Lot Size PM Owner's Name LP6 Address a. )C� �T i(74� 'l_ Phone C / Contractor's Name Aci ense No. 10.0 c 'S/ Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION D PUMP INSTALLATION X SYSTEM REPAIR D OTHER ❑ 70 DISTANCE TO NEAREST: SEPTIC TANK 10fTtAJ(--, SEWER LINES J DISPOSAL FLD PROP. LINE ��+w�,re /pp o� FOUNDATION � AGRIC TURF EL OTHER WELLSLtT'e►�i PITS/SUMPS ��(TNE k IN E R BLE AREA CONSTRUCTION SP7!CIFICATIONS ❑ Indus#ria/ ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private �Gravel Pack ❑ Tracy Type of Casing .:�T��.0 _,_ Specifica#ions �j ❑ Public D Other ❑ Delta Depth of Grout Seal SQ p Type of Grout El Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done h Well Destruction D Well Diameter Sealing Material (top 50') - Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION LJREPAIR/ADDITION C1 DESTRUCTION L1 (No septic system permitted if public sewer is V i available within 200 feet.) � w Installation will serve: Residence— Commercial— Other Number of living units': . Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ElType/Mfg Capacity No. Compartments -� PKG. TREATMENT PLT. El Method of Disposal Distance to nearest: Well Foundation Property Line y' LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS D Depth 1 Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ * , I hereby certify that I have prepared this application,and fhat 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." 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." i The applicant t call for all required inspectio s. Complete wing on reverse side. � Signed Title: r XE Date: �}- (' ] I �vE7 J at/ dkh+ FOR DEPARTMENT USE ONLY Application Accepted by fDOf Date UY Area 04 Pit or Grout Inspection by ate final nspect`'O Date I Additional Comments.- 0 omments:❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE 13INFO AMOUNT DUE AMOUNT REMITTED CASH K* �1 RECEIVED BY DATE PERMIT`NO. + EH 24[REV.10/83) �`r t� a O i -.y. '7/1 EH 14-26 �]