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"0," ! APPLICATION.FOR,PERMIT 1 4- x SAN JOAQUINaLOCAL HEALTH DISTRICT 1601 E. HAZELFON-AVE., STOCKTON, CA Teleplione 12091 466-6781' - . PERMIT EXPIRES;1 YEAR FROM DATE ISSUED, in:'Tri licatel s f., r1 t"° - i 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,In �,� +� f�?�+9 .S iC, ,.:;x. M •., ,s+ z; " " C'.w".° *z 1 /N�Lt1 s' ril9r(A.. V i – City 9�WC� . Lot Size PM i Job Address ? Owner's-Name e� Address = 4' t"' 4S$-\Phone ` _.. &.4,— �/�'�t License No. Phone Cl Contractor's Name - TYPE OF WELL/PUMP: 1 NEW WELL WELL REPLACEMENT ❑ DESTRUCTION El`. PUMP INSTALLATION. ElSYSTEM REPAIR ❑ OTHER ❑ DISTANCE T,O�NEAREST:_SEPTIC TANK �x — SEWER LINES — DISPOSAL FLD.1{ PROP. LINE tom" �W FOUNDATION AGRICULTURE WELL! OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELD PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Open Bottom ❑ Manteca Dia. of.Well Excavation Dia. of Well Casing ic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1",4 amest � . ❑ Public g ❑ Other ❑ Delta Depth of Grout Seal Type of Graut !!�� ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material itop 50'1 } Depth' "" Filler Material {Below 50")--+,— �. TYPE OF SEPTIC WORK: NEW INSTALLATION LJ REPAIR/ADDITION ElDESTRUCTION El (No septicr'system permitted if public sewer is y available within 200 feet:}q,,, 1 e� Installation will serve: Residence— Commercial_ Other " I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: --Water table depth _ SEPTIC TANK C1TypelMfg �Capacity� No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ° t Distance to nearest: Well Foundation Property Line t t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED" `" -� 4 sfence to nearest:`"`"WBII ndauon op-erty�Line="' SEEPAGE PITS, ❑ .Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line k DISPOSAL PONDS ❑ ` r 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. I 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^4r, � ri employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring o 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 subige to workman's compensa t tion laws of California." t' . The applicant t 11 for alfrequired i ctio to drawing on reverse side. t w. Title: Date: +Signed ' FOR DEPARTMENT USE ONLY r -. rt r � Area .--� Application Accepted by Date i; Pit or Grout Inspection by e spection by Date anal In _ -- i� _ ! Additional Comments: ..f. - ❑ Stk 466-6781 ❑ Lodi 369-3621" 0 Manteca 823-7104 ❑ Tracy835.6385„1 } Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton"Ave P.O. Box 2909, Stk., CA 95201 t FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NQ. INFO 1 .EH 13.24(REV.1oraas "3;` o .r b� [r`'sS �s 5 b-lj EH 14.26