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APPLICATION FOR PERMIT ):00 SAN JOAQUIN LOCAL HEALTH DISTRICT r "�"'1E01 E, HAZELTON AVE.-, STOCKTON, CA Telephone (209) 466.6781 r� � I� PERMIT EXPIRES TYEAR FROM DATE ISSUED Pete, Lf-0'r Cap63�` Ti3Z t (Complete in Triplicate) 01fNc$GtrL M 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 l made in compliance with San Joaquin County Ordinance No.549 for r sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address _ , �� d![/fN� ,� City Lot Size PM Owner's Name ,Address Phone Contractor Addresse?LW � License No. Phone TYPE OF WELLIPUMP: -NEW WELL (�". WELL REPLACEMENT.❑ q DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR Q�* OTHFt ❑ r DISTANCE TO NEAREST: SEPTIC TANK '2"f SEWER LINES ��_ DISPOSAL FLD.,7,0 PROP. LINE KS —FOUNDATION ZS AGRICULTURE WELL --i OTHER WEAL,---'PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSS, ' It D Industrial ❑ Open Bottom 13 Manteca Dia. of Well Excavation _—_,12•- •• Dia. of Well Casing " DomesttclPrivate DC Grave! Pack ❑ Tracy Type of Casing t �T Specifications ryi f 1 Public n Otper ❑ Delta Depth of Grout Seat 3D Type of Grout dksom&I 1 I Irrigation l-Approx. Depth I I Eastern Surface Seal Installed by� I Repair Work Done 0 Type of Pump H.P. 2 .._,State Work Done Well Destruction Q Well Diameter Sealing Material Ctap 50'i Depth Filler Material {8efow 50'1 - ' TYPE OF SEPTIC WORK: NEW INSTALLATION IJ REPAIR/ADDITION l I DESTRUCTIONI iNo septic system periiiiiled it public sewer is •/ available within 200 fee�a � Installation will serve: Residenoe— Commercial„_:_ Other k 1 r 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: r' Water table depth 't SEPTIC TANK ❑ Type/Mfg Capacity __— No, Compartments PKG.TREATMENT PLT. ❑ y McMod,of Disposal _ Distance to nearest: Well Foundation ~Property Una { , _ r LEACHING LINE ❑ No. & Length of lines T,ota[,length/sized FILTER BED ❑ Distance to nearest: ' Well Foundation Property.Line I SEEPAGE PITS I'll Depth Size Number I SUMPS L1 Distance to nearest: Well Foundation Property.Line + DISPOSAL PONDS ❑ "Y �� .� " ' I hereby certify that I have prepared this application and that the work will be done,in accordarice with San Joaquin'county ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. 14 "—t . Home owner or licensed agent's signature certifies the following:"I certify.that in the performance of the woik for which thf#permit is issued, I shalt 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,14hall,-amploy.persalis•su_bibbt to workman's compensa- tion laws of California." The applicant II regri coons. Complete drawing on rse a. 1• �" s. Signed X Title:–_`L Date: - FOR DEPARTMENT USE ONLY;sA�& ' f Application Accepted by ` D ` AraePit or Grout Inspection by DataZFinal Inspectionlip Dated ! Additional Comments: r � 16 El Stk 466-6781 ❑ Lodi 369-3821 ❑ Manteca -7144 ❑Tra 835-6385 '��: .; - r ; Applicant- Return aft copies to: Environmental Health Permit/Services.1801 E. Haxeltan Ave., P.Q. Box 2009, Stk.,CA 95201" jai C a a _ra,# I" /apD71 , C3rOL�'iG7�1{iI�I G I l�j� LTG ' �0 Z.., INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'µp• �] q +.EH 3-?4 ( O—j Eli ICX