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V N - I a APPLkATION FQR PER-MFT,..-.,,, _, SAN JOAQUIN LOCAL"HEALTH DISTRICT l 1601 E. HAZE T ON AVE., STOCKTON, CA TelepR ne (209) 466-6781 j' PERMIT EXPIRES 1:YEAR'FROM DATE ISSUEO,n zoaC. 'o r#if L, I RIVP ' 4 (Complete in Triplicate) i ! - . 3fl�r j"e,; '". r Y 1 4 :x0 no r `r-", r 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 Ryles and Regulations of the San Joaquin Local Health District: • 6 ^ :�. t - S} �� ! fi � - n 'S -"`+ .(nS•1.}i�:".�� t4#� �ltr , ..� Job Address �1L_ 10 .9 � i� k! r Citylz+' Lot S!ie iJ d PM ... _... - Owner's Name _� Al �O J=,) Address - Phone Contractor F Address _ 1� License N 4 Phone ! a •-3 '... TYPE-OF-WELL/PUMP.._...—. -',NEW-'WELL"❑-•- WELL'REPL`4'CEMENT•`❑ "'-`-" 0"- PUMP INSTALLATION ❑ „ SYSTEM REPAIR ❑ OTHER ❑ 6 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED-U.SE--T_Y.P.E-OF W,,ELL.o.....:WP_ROBLEM.AREA...r.CONSTRUCTION-SP_ECIF.ICATIONS— ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.!of.W,elkExcavation Dia. of Well Casing ❑� Domestic/Private ❑ Gravel Pack ❑ Trac T e of Casing`. E Y Yp g Specifica#ions ❑ Public F-1Oth'e'r ❑ Delta Depth of Grout Seal - Type.of Grout ❑ Irrigation --Approx. Depth Ll Eastern Surface Seal Installed by` Repair Work Done ❑ Type of Pump H.P. State Work Done-J 4#1 Well Destruction ❑ Well Diameter —Sealing-Material-I top.50'1. f' Depth Filler Material;Below 501 t TYPE OF SEPTIC WORK: NEW INSTALLATION ti-- PAIR/ADDITION ❑, DESTRUCTION ❑ (No,-eptic system permitted if public sewer is J �$ J J_�J, U .= available within 200 feet.) 6` installation will serve: Residence Commercial her A^ . k Number of living units:-]—:I Number of bedrooms Cflaracter of soil to a depth of 3 feet: Water table depth f ,FSE,P71C'TANK ❑ Type/Mfg ; Capacity_zaJ1S1_ No. Compartments PKG`TREATMENT PLT. ❑ n �/{ ; f- Method of Disposal Y Distance to nearest. Well Foundation Property Line��— , LEACHING LINE V_,No.�& Length of lines ' Total length/size FILTER BED ❑ Distance to nearest: i`t We Foundation Property Line r SEEPAGE PITS ' ��epth- 'r Size%If b f r Number + SUMPS s.y ❑ Distance;to nearestc y Well., Foundation 'Property Line DISPOSAL PONDS ❑` r A I WF- `. *, ,.. t, r'' - } t I herebyceriify}that I'ha've prepared this application"and-•tFiaf the'-work will be done in accordAcWw!th San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local.Health'Distr'ret. �. I Home owner or licensed agent's signature cerfifies the following:-�l 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 becoke subject to workman's compensation laws'of California."Contractor's hiring or sub-contracting signature Zles the following: " ify that in the rforrriance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tio''a California.' ;' t The applicant call for all eq r d ins ion i o I e drawing on ers'e side. t Signed Date: ;I FOR,DEPARTMENT USE ONLY Application Accepted by Date _511d Area Pit or Grout Inspection by ate 117/274 Inspection by Date Additional Comments: # ❑ Silk 466-6781 ❑ Lodi 369-3621 b Manteca 823-7104` ❑ Tracy 835-6385 Applicant- Return all,copiesto fEnvironmental`Heakh Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4 �JFEE �a INFO AMOUNTdDUE AMOUNT REMITTED " R RECEIVED I3Y DATE PERMIT'NO. 1 CASH EH + EH1324(REV.1 14-26 ....._x . /857 � �