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%.� APPLICATION FOR PERMIT ,.,i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA e Telephone (209) 466-6781 N 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 Ordina ce N . 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. /3p Job Address 2 City r Lot Size /" 7 6 1 PM 47 /y� /y1 Owner's Name Address 2 6 Phone /- V V • / 7N � ` - x:02 Contractor License No. Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT 0 DESTRUCTION 0 PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER 0 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 0 Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �\ ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public FI Other FI Delta Depth of Grout Seal Type of Grout_. I I Irrigation —Approx. Depth I J.Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump 11 H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop SO') Depth Filler Material (Below5v) TYPE OF SEPTIC WORK: NEW INSTALLATt N 1 1 REPAIR/ADDITION ESTRUCTION 1 I INo septic system permitted it public sewer is available wi bin 200 t.l Installation will serve: Residence Commercial Other Number of living units: _ Number of beadrooms�_ 1/ Character of sal to a depth of 3 feet: Water to J SEPTIC TANK 0 Type/Mfg Capacity--._ No. Compartments PKG. TREATMENT PLT.❑ ��/� �r Method of Dido I Distance to nearest: Well roundation Property Line LEACHING UNE 0 No- 8 Length of livres Total length/size FILTER BED ❑ Distance to nearest: a - ` Property Line SEEPAGE PITS I I Depth Size _ _ Number SUMPS ❑ Distance tonearest; Well f Foundation Property Line DISPOSAL PONDS 0 1 hereby certify that 1 have prepared this Application and that the work will be donAn 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 certiNt 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-cwntracting 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 st call for all re .red_insp Stl9ns. Complete drawing on'reverse side. Signed X � Title: a. & ri-LAA--. Date: FOR DEPARTMENT USE ONLY �-^ Application Accepted by �- lr? Date Pit or Grout Inspection by Date Final Inspection by D - --- ,' Date ' Additional Comments: , ^�"'s' �- ��'1- 0 Stk 466-6781 0 Lodi 369-3621 0 Manteca 823-7104 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services, 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE tom` y.PyyEERMIT'NO. . EH 13.31(REV t:n5i . j - / / /J/) ^/ EH 1428 V/ JJ NNN GG!! [IFI /