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n F1 F1APPLICATION FOR PERMIT QUIN LOCAL HEALTH Di ® r SAN JOA O STRICT r� B 1601 E. HAZEL T ON AVE., STOCKTON, CA J + Telephohe (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �1R() v[lPA. OES {Complete in Triplicate} EN�;RO\ 1 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 7 -5-e 7 �D � /7 /Y City l fiV�l- Lot Size PM � a J r Owner's Name I./'PR II /J—"45J",0)P_Address 5AVZPhone Contractor. AVII S,�Address ell"" JU_c'_41ic License No.Ak/a", _Phone F TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR -�O OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FJ FOUNDATION AGRICULTURE WELL T-OTHER WELL PITS/SUMPS 'I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS "E ❑ industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation' _ Dia. of Well Casing _ _. ,Domestic/Private ❑ Gravel Pack ❑ TracyType of Casing Specifications M Public C1 Other Cl Della. Depth of Grout`.Seal Type of Grout _ I I Irrigation Approx. D4pth "t-1 ltdtern S� ace Seal lnstalled?by Repair Work Dona ❑ Type of Pump S-al.r� H.P. 7 ! State Work Done v /1 Well Destruction ❑ Well Diameter Sealing MatenaF-top 50' Depth Filler Mzi rial Ael{n 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION f'i Rt:i AIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is r - available within 200 feet.) # Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms rl rCha,acle, of soil to a depth of 3 feet: Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I PKG. TREATMENT PLT. ❑ Method of Disposal I `� Distance to nearest: Well Foundation Property Line II. Fjj� LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: i Well Foundation Property Line SEEPAGE PITS I i Depth Size _ _ Number F1 SUMPS Ll Distance to nearest: Well Foundation Property Line _ DISPOSAL PONDS 171 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 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 i 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 Vor require c ' ns. Complete diawing on rev rsa side.�.Signed X � 'Title: Date: I 1 7 ': F1P fMENT USE ONLY Application Accepted by Data �� "�� Area .� Pit or Grout inspection by D..'_ Final Inspection by. .:'`�/1�� Date r Additional Comments: ❑ Silk 466-6781 ❑ Lodi' 369=3621 ❑ Manteca 823-7104" ' U Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ji