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e f N APPLICATION FOR PERMIT SAN JOAOUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,-STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAAFRO MDATElISSUED (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.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Addressco r '"{ S " Y \ City fo of Size PML2 S r Owner's Name '.C6 P � �Address ;LJ7 .i Phone Contractor f✓E 'w _ [__ }LL Address '350 icense No. !-Phone TYPE 8�s '•TYPE OF WELL/PUMP: � NEW WELL WELL REPLACEMENT'❑ - - ' DESTRUCTION ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC.TANK SEWER LINES DISPOSAL FLD. PROP. LINE ff FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS --INTENDED-USE' TYPE'OF'1IVECL— -PROS►VI-AgEA'' CUN—STRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom If Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack , Dia. of Well Casing O Tracy Type of Casing ❑ Public - Specifications �" "�❑'OtFerDelta Depth of Grout Seale' ❑ Irrigation Type of=Grout g I _�4pprox.,Depth, ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. I { state Work Done Well Destruction_ ❑ Well Diameter. (_ 'Sealing Material (top 50'1 +' r. bepih 1 i Filler Material'(Below 50'f r TYPE OF SEPTIC WORK: NEW INSTALLATION- AIR/ADDITION ❑ DESTRUCTION ❑ Wo septic system permitted if public sewer is r available within 200 feetl) Installation will serve: Residence —Commercial Other Number of living units:—A— Number of bedrooms Character"bf soil to a depth of 3 feet: SEPTIC TANK 1 Water table depth) �fype/Mfg CSD C r Capacity_ f'S_ No. Compartments PKG. TREATMENT PLT. 0 } DiMethod of Disposal Distance to nearest: Well Foundation�__ Property Line51 6Q .51 NEE M ,_ LEACHING LINE C1�. & Length.of lines _- Total length/size f--.-. FILTER BED ❑ Distance to nearest: Well Foundation Property Line � SEEPAGE PITS C7 Depth tSize Number SUMPS ❑ Distance toInearest: Well {; Foundationx k Property Lino DISPOSAL PONOS. .;.-❑ r. , � -�# •f � • ,_ r� 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-signatureacertifies_the-following:-'-q_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 compensationFlaws of California."Contractor's hiring or sub-contracting signature certif"es the following: "I certify that in the Performance.of the work for which this ler ii is issued,l shall employ on la of California." P P Y persons subject to workman's compensa' The appficanMcall for II r�ro �Ctlii Coplate drawing on rev rse`side. Signed Title: OR DEPARTMENT �S�EON�LY Application Accepted by - Date r 5 Area Pit or Grout Inspection by Date Final Inspection by a r� � � fte _'4S + AdditionL-6781 omments: � "Wv' - � � - ❑ Stk -_ C1 Lodi 369-3621 .0Manteca 823-7 _ 104 ❑ Tracy 835-6385 Applicant - Return all copies to_lE`vironmental Health Permit/Services 1601 E. Hazelton.Ave., P.O. Box 2009, Stk„ CA 95201 rri r 5 # r P o w•�r�°� tFrS �' +,/orr 1S5k8xJ.: FEE AMOUNT DUE. AMOUNT REMITTED CK INFO RECEIVED 8Y DATE PERMIT NO. + EH 13-24 fRE'V,va51 EH 14-28 -Ll LSwVol� -'