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APPLICATION FOR PERMIT .� I., SAN JOAQU.IN LOCAL HEALTH DISTRICT 1601 E. HAZEL TON AVE., STOCKTON, CA 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. I Job Address / N,' y — City Lot Size 1/0 6Lf�6 PM I � Owners Nam Address Contractor a ddress A3 OX � S� License Nal. -.. �Phone &;1 0 TYPE OF WELL/PUMP: NEWWELL WELL REPLA gEMENT ❑ DESTRUCTION ❑ u-�0 PUMP INSTALLA710 SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD:�_ PROP. LINE FOUNDATION ,AGRICULTURE WELL HER WELL' h ` •PITS/SUMPS ! INTENDED USE TYPE OF WELL PROBLEM AREA M CONS,IiUCTION SPECIFICATIONS ##- ❑ Industrial Open Bottom ❑ Manteca Dia. of VY II Excavation Dia. of Well Casing 1XDomestic/Private ❑ Gravel Pack ❑ Tracy Type f asing Specifications x ❑ Public ❑ Other ❑ Delta Depth,o�' rout Seal - Type of Grout t ❑ Irrigation ---Approx. Depth ❑ Eastern Surface eal Irnsrailed by " Repair Work Done Type of Pump H.P.^ .r — State Work Done Well Destruction ❑ Well Diameter ry Sealing Material lt" } Depth_ Filler Material (B.t W 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION gi-rDESTRUCTION ❑ (No septic system permitted if public sewer is 9 ; available within 200 feet.) nstallation will serve: Residence— Commercial t Other 1�1 —N r_of living-units: -. Number{of-bedroom$ _ . Character'o o a'depth of 3-feet: " t Water table depth SEPTIC TANK /Mfg Aftf Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal l Distance to nearest: Foui dation Property Line I t LEACHING LINE Q No. & Length of lines Total length/size— FILTER BED Cl Distance to nearest: Well Fa ndation rty Line j SEEPAGE PITS 0 Depth Size ''w Number s SUMPS ❑ Distance to nearest: Well Foundalion � -� Property Line i DISPOSAL PONDS ❑ I hereby certify that 1 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 Sap 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." The applicant Tdoall fo I requi inspection tete drawing on reverse side,.. ,, J Signed T' ."� Q� Titley "t/ v - -- Date: 3—2 0 R7 1 a FOR DEPARTMENT USE ONLY I Application Accepted by `Date Area v — i Pit or Grout Inspection Date Final Inspection by `�`' - t Date ' Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3521 ❑ Mante 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t FEEAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE i 3 G, =INFO 324 EH 26+ EH 141REV.1i851 n