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i 3r `( APPLICATION FOR PERMIT / SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 }p L 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address L[ri, , T r1/� A ML.h.� IZ-.>(,;,(,J N Afi ttr� Cz-�( t 1 Lot Size pq PM ZS Name-R, �� 1�(:f.�:f Address Iz'3(<,�-, f 24 ir 001,,6E a Phone w Contractor AI Y AddresstQaL; a–I :XZ� License No. AErKi(�=. Phone ZJ��-121L TYPE O_F_W_ELL_/PUMP: NEW WELL ❑ WELL REPLACEMENT i7 DESTRUCTION ❑ PUMP INSTALLATIONA&f*4L.,A.AT-SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO,NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL __._. OTHER WELL__— PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! 119(fustrial ❑ Open Bottom L-, Manteca Dia. of Well Excavation Dia. of Well Casing D rmestic/Private LI Gravel Pack ❑ Tracy Type of Casing Specifications Public I I Other 11 Delta Depth of Grout Seal Type of Grout------ -, I I irrigation __ Approx. Depth I i Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump V.J_ H.P. ' 'KL State Work Done Well Destruction ❑ Well Diameter Sealing Material(top 50') �+1 � Depth Filler Material (Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I l (No septic systern permitted it public sewer is available within 200 feet.) UV 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.U 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 LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this perrrut 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 subcontracting 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 Califoto -1. The appli nt. f t''11 for j squired inspections. Complete drawing on a rse sidg:. Signed Title: 4. Date: rrff ,yR DEPARTM NT USE LY Applica n ed by Date / Area n Pit or Grout Inspection by Date Final Inspection by � '� Date h' -i � Additional Comments: C Stilt 466-6781 ❑ Lodi 3643621 ❑ Manteca 823-7104 C Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2009, Stk., CA 95201 ' FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. NFO CASH Ell 13-24(REV.ria sl '�� --� i. EN t,.m I b o 0