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P-9-v te, Ccq_) USA I p ^4 Y APPLICATION FOR PERMIT l./ n4 3 ` a SAN JOAQUIN LOCAL HEALTH DIST1f[WN., 1601 E. HAZEL T ON AVE., STOCKTON,✓1I1� (JQrvry 9 t'C2 Telephone (209) 466-6781 PERMIT EXPIRES 'YEAR FROM DATE 199J 0 Ed 6 1330 tek (Complete in Triplicate) Vq� LIC0pQQ!J!r�i coIfNTy Application is hereby made to the San Joaquin Local Health District for a permit to const u'Ctiv�i�hNblEiwA 1 Iriq bi1t� J sescribed.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for�yyel(/pump and theoi"J ,I II'4%oNtions of the San Joaquin Local Health District. KU J Job Address3 '� t'wr'`"" City Lot Size PM Owner's Name /y"Z= Address, � l lut � Phone 20-1-7 S Contractor Address License No.Y 7'�{8 S/` Phone �S TYPE OF WELL/PUMP: IS&W WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLAT N O SYSTEM EPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1VW DISPOSAL FLD.'jQ/ P OP . LINEFOUNDATION AGRICULTURE WELL OTHER WELL�L� PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 9omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications /V F1 Public J" Other /41-Delta Depth of Grout Seal Type of Grout I I Irrigation .a Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State.Work Done Well Destruction O Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 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. Home owner or licensed agent's signature certifies the following: "1 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." The applica must 11 for all requ'a inspections. Complete drawing on reverse side L Si ed X Title:\C�'r `' ate: nFOR DEPARTMENT USE ONLY �t Application c e tedy _0, _ ` L/�._ Date 0 l? Qo Area T3Z Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AAMOOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. . EH 13-24(REV.1/851 ;_/Z � O 160V1 D`� QO �?� EH 14-26 197 r�