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APPLICATION FOR PERMIT I Sr! C: $k 'blq SAN JOAQUIN LOCAL HEALTH DISTRICT } lobi 23-go1 o -b 1 1601 E. HAZELTON AVE., STOCKTON, CA _ Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f (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 i made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 to,well/pump and the Rules and Regulations of the San Joaquin Local Health District. 1 t �� CPN ° ( 00 y in C P �A-e LZ City J 0di Lot Size PM L Job Atltlress Tf '1 rynJ� II '' ^� (( - Owner's Name Y �1C4N PIG FV1tI.OS Address y�Ob Lt)• F'Y.>`.! (,, PhonB� 3� prrG/ /t's. Volvo Contractor ddressmS�/ License No. 5LZZ4g ' prone (o f 8 12— N TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT u DESTRUCTION ❑ 1 1 — PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER lg (jcu� 1pDy�n4] DISTANCE TO NEAREST: SEPTIC TANK 7 r SEWER LINES 7 5D DISPOSAL FLD. 'PROP. LINE /PJB I s FOUNDATION 1 �' AGRICULTURE WELL,-hf OTHER WELL PITS/SUMPS k^ 10 i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I st L1 Industrial ❑Open Bottom F] Manteca Dia. of Well Excavation L `Dia, of Well Casing 1 C Domestic/Private ❑Gravel Pack ❑ Tracy Type of Casing N JA- Specifications zv I„y ok- tS .1111 I'I Public ❑ Other 11 Delta Depth of Grout Seal Q r A Type of Grout-B9tdr, t w U PL 1 I I Inigation —.APMox, Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) f Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet. Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ _ Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE Cl No. 8 Length of fines Total length/size /(1 FILTER BED O Distance to nearest: Well Foundation Property Line l_ SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to neatest: Well Foundation Property Line - DISPOSAL PONOS ❑ 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 D13trict. � 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, 1 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,1 shall employ persons subject to workman's compensa tion laws of C ornia.- The app' nt at call for all equpections. Complete drawing on reverse side. Signed % Jaw- Title: F DE RTMEN7 USE ONLY Application Accepted by t Oats 16 /�'ty Area — rc v3- < r F, a,ra t Pit or Grout Inspection by Date Final Inspection by� Data 5. c e-«t rPs, Additional Comments: - L,,._r -.1 r- ❑ Stk 4666781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835-6386 Sr o-r.t..t rw Applicant- Return all copies to: Ernmonmental Health Permit/Stevrem 1601 E. Hazelton Ave., P.O. Box 2009, Six., CA 95201 TT-'�6 rz r."C.vet vtl Ci- CK I INFO AMOUNT DUE AMOUNT REMITTED I CASH RECENED 6r' DATE PERMIT NO. ♦'EH 124EH 1120 EV 11. 8'q .�. /-o'� 9/ 9i-oal