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N APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1801 E. HAZELTON 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 061"for a permit to construct end/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.849 for sewage or No.1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, 5,fp" Ai n0 Job Address IiI W`QST b (�Il� �"� ' Ciry Lot Slze PM Owner's Nam yk(C MEONARDINI Address 05-4- \M (kubwd a Phone i Contractors Name 13y bW - License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ PUMP INSTALLATION CI SYSTEM REPAIR ❑ OTHER ❑ 1 DISTANCE TO NEAREST: S€PTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r S ❑ Industrial ❑OFen Bottom O Manteca Dis,of Well Excavation OIa-of Well Casing ❑ Domestic/Private ❑'Grevel Pack M Tracy Type of Casing _ Specifications ❑ Public O Other Q Delta Depth of Grout Seat, J — Type of Grout - ❑Irrigation --Approx. Depth Eastern Surfer's~Seal Inst alled'tiy' tepa Repair Work Done •❑L_Type..of Pump, ...._H.P. State Work Done Wall Destruction - ❑ Well Olamhter Sealing.Material.itop-804 -- -^-- Depth Filler Material.16arowtb09_ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 11 _DESTRUCTION❑ (No septic system permitted R public sower available within 200 feet.) Installation will serve; Residence_ Comme{oial_`biltei'(1}d✓31G. NOti16' Q(K i Y Number of Irving units:_ Number of bedrooms Character of sol to a depth of 3 feet: - Water table depth !' SEPTIC TANK /qC Type/Mfg -� '-Y� '1= Capacity Qd &Ate No. Compartments PKG.TREATMENT PLT.❑ Method of Disposal Distance to nearest: Wal Foundation Property Line � 1 P i LEACHING LINE ❑ No. &Length of Imes Total length/sue FILTER BED iK Distance to nearest' Well(OpOLL Foundation. o Property Line 27 or SEEPAGE PITS ❑ Depth Size Number ' r SUMPS 11111, Distance to nearest: Well Foundation Property Line -DISPOSAL PONDS ❑ r 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: "I certify that in the performance of the work for which this permit it issued,I shell not d employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following:"I cerdty that in the performance of the work for which this permit Is Issued,I shall employ persona subject to workman's compensa- tion laws of California." ' The applican ust c I for all required inspections)Complete drawing on reverse side. 7 Signed X �>--R-.e.l Title: 1465- ML 2.r Data: ' DEPARTMENT USE ONLY - Application Accepted /�Ly//�� Date Area Pit or Grout Inspection-by Dam Final Inspection -, ( Date F Additional Comments: -- ❑Stk 486.6781 ❑ Lodi 369.3821 a Manteca 8a3-7104 ❑TrecY 83548!88 Applicant-Return all copies to: Environmental Health Permit/Sekices 1601 E. Hazalton Ave., P.O. Box 2009,Stk., CA 962111 • /9914 lav INFO AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY DATE PERMIT-NO. e i WICK; a v.tatml �t S aCsoa gL, $' �g