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.. law APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA '— Telephone (20S) 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.Thi•,Application is made In compliance with Sen Joaquin County Ordinance No.549 for sewage or No.1862 for well/pump and the Rules and Regulations cf-,he San Jcaquin Local Health District. 1 /,/1 r Job AddresO` SOW I P S Z City C6"'N l) PNI, 0 M �LgotSize Owner's Nems �nn Address 1 / Y �7ClJ/f°S I�LV// one Contract Address License No 6 .Phone -33 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT.�❑,,(( DESTRUCTION ❑ PUMP INSTALLATION SY^STE�M/IREPAIR p OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 0 SEWER LINES �f3L��-y�.I-�t—�� DISPOSAL FLO._ PROP.LINE FOUNDATION �.(L� AGRICULTURE WELL1,3.trltz OTHER WELL PITS/SUMPS CCC INTENCISD USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (.. ❑Industrial ❑Open Bottom ❑ Manteca Die.of Well Excavation Dia.of Well Casing XDorneetic/Private ❑Gravel Peck ❑Tracy Type of Casing Specifications IV•1 ❑ Public ❑Other ❑ Delta Depth of Grout Seal Typo of Grout_ ❑ Irrigation _--Approx. Depth ❑ Eastem Surface Seal Installed by ZZ Repair Work Done ❑ Type of Pump H.P. State Work Done at ie fo jq 2 5 WgIL Destruction [J Well Diameter Sealing Material(top 50'1 % iSu ,- P Depth_ Filler Material(Below 50'1 — TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION K DESTRUCTION ❑ IND septic system permitted if pub,'c sewer is available.!thin 200 feed Installation will serve: R dance X— Commercial_ Othor Number of Wing units:7_ Number of bedrooms C— Character of soil to e 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—_ LEACHING LINE ❑ No.&Length of linea Total length/size---- FILTER ength/size __FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line _ DISPOSAL PONDS ❑ I hereby cendy 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 compunsation laws of California."Contractor's hiring or sub-contracting signature cart8les the following:"I cenity that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's comperes. tion law,of California." The applicant must call for all re/g7uired inspections. Complete drawing on reverse side. Signal X 1 Ca_d Tida: emn ler — oats: Y-,3- FOR DEP TMENT USE ONLY (((j/// �Q C✓_/� _ Application Accepted by Date Area // o e� Pit or Grout Inspection by — Dote final Incpaction by is ��-v Date� '' LJ Additional Comments: ----- ❑ SO, 4668181 Lodi 589-3621 ❑Manteca 873-%104 C1 Tracy 93f>'6385 Applicant-Return ell s6piei to:Environmental Health ParmiV SeNices 1601 E.Hazelton Ave., P.C. Box 2009, Stk.,CA 95201 FEE gMM1hT DUE �MUREMITTEO CASN RECEIVED BY DATE PERMIT'NO. -NFO —___ fN11N IaFV.i.n:. 3J ��O 1C SH EN 1�6 -