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APPLICATION FOR PERMIT SAN JOAQUIN LOCZHEALTH DISTRICT �1 - 1601 E. HAZELTON•AVE., STOCKTON, CA f Telephone (209) 466-6781 `t ERMIT EXPIRES I YEAR FROM DATE•ISSUED ' `.'-. (Complefe in Triplicate)'' Y •k y).'l-nt t' "^. 't J,'.a. 3.. . .J l: ...j.i if, t' "� ,.l• .i... -5 Applic'ation4 -h made to the San Joagfuin Local Health District for a permit to construct and/or install the work herein described, This application is made In com liance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and R JLocal Health District. , a Y p 4 Regulations of the San Joaquin ..''I1 9 u� Job Address �!7 ' ,_�[� LQ�cL City i&&c c ifl Lot Size ' PM Owner's Name ll^G/�.� /- r�t;cu�1/ Address a 4) 'S-0.. a-I"'L`�[: ?hone -d 3 Contractor Address License No. Phone TYPE OF WELL/PUMP: - NEW WELL ❑ 'WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATIO /❑ SYSTEM REPAIR ❑ OTHER . DISTANCE TO NEAREST: SEPTIC TANK f - / !C-� SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION`f AGRICULTURE WELL OTHER WELL — PItS/SUMPSy INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Die:of Well Casing ❑ Domestic/Private Q Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction . ❑ Well Diameter Sealing Material stop 50'4 t Depth Filler Material(Below 50'i ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is �q ailable within 200 feet.) 111 ' Installation will serve: Residence_�Commercial_ Other f Q(! Number of living units: Number of bedrooms �r 4 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg r^ Capacity No. Compartments 4 U} f PKG. TREATMENT PLT. ❑ �} t Mathod:of Disposal Distance torn artist: Well Foundation Property Line LEACHING LINE ❑ No. & Length of►hies ' ` f Total length/size r FILTER BED ❑ Distance to nearest: Well t Foundation t Property Line SEEPAGE PITS ❑ Depth Size f —_ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I--] I ++' 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' •t° 1 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 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 a 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 Calitomis." The applicust call for adl qult r a linspections. Complete drawing on reverse?side. /• (� -/ Signed X �i(/J �� Title: '(9 01,141 6-AE-1 Date; dgi(a FOR DEPARTMENT USE ONLY Application Accepted by ' Date Area / r fit or Grout Inspection by � � Date Final Inspection by '—✓�-' date OrNS Additional Comments: �+V C l P�� r.� dv i r. •o� - e� ❑ Stk 4666781 ❑ Lodi 369-3621 ❑ anteca 873-7104 ❑Tracy 83 Applicant-Return all copies to: ervces azeltonve., ox : Environmental Health Permit/Si1601 E. HAP.O. B 2009, Stk., CA 9tWll , ' �r FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY PATE PERMIT N0. i EH 13.24(REV.1/65) c C EH 14.28 S♦ �� S • ©� i()�