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!I� �- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELiON 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.599 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. ` Job Address y m h C 99 1 City Lot Size�_- (�..sae� PM Ownei s NameAddress �� S N Phone 9 L1 -4 _ Contractor l TT 1—y'tn Address License No. Phone -' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP- LINE FOUNDATION AGRICULTURE WELL OTHER WELL PRS/SUMPS - /T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V`� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout Q ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. _ State Work lone -}-' �- Well Destruction ❑ Well Diameter Sealing Material(top 501 Depth - Filler Material(Below 509 TYPE OF SEPTIC WORK: NEW INSTALLATION��EPAIR/ADDITION DESTRUCTION O (No septic system permitted if public sewer is NewFF available within 200 feet.) _ Installation will serve: Residence_ Commercial Other 1 Number of riving units:_ Number of bedrooms Character of soil to a depth of 3 feet Water table depth SEPTIC TANK C'r Type/Mfg Capacity iQ�AL No. Compartments. PKG. TREATMENT PLT.❑ + f- Method of Disposal' Distance to nearest: Well._ rte Foundation 10 Property Line ;'s + LEACHING LINE 2'�No. & Length of lines Total length/siz nea FILTER BED ❑ Distance to rest Web ("CO" Foundation Property LineYZ- P ,1- L..F� Number SEEPAGE PITS C�Depth �„S t Size SUMPS ❑ Distance to;nearest: Well 2oa4 Foundation ILD f- Property Line DISPOSAL PONDS ❑ - 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 Lrules 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 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- L tion laws of California." The applicant must c`al'l for-all,required inspections. Complete drawing on reverse side. Signed Title: 6i4ll-e-GL Date:I`�^Z'S �S �OR DEPARTMENT USE ONLY Application Accepted by �:.\Y\q.,� 1L.A� Lw,/� Date - 'Area b Pit r Grout Inspection by L/a`♦z`�.y1�"�"''�r'-�"{"{ ^ate♦ Final Inspection Date Additional Comments: R�-X.ru.e?J X W' JLa.JtJ .�w� Gu♦ ❑ Stk 966-6781 ❑ Lodi 369-3621 ❑ Manteca 8&7143 ❑Tracy 835.6385 Applicant- Return all copes to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECDVED BY DATE PERMIT'NO. L. EH 1124 uiE iias) w raze R i LY T i >T K � 0 �• � Y d'c N ��.