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°t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. FiAZEL i ON AVE., STOCKTON, GA ` Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I1/ /,qG7r 144 2— (Complete in Triplicate) r: F/ A0A, 99k - DSO 5' . Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work h ein described.This appl' n is f made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 18.62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.- //yyyyb Job Address City LotIM,� - Owner's Name ddress -LD�( /Y, V y -Al Phone Contractor /� ` ��r SV,5 Address License No. Phone i TYPE OF WELL/PUMP: NEW WELL flV WELL•REPLACEMENT ❑ DESTRUCTION ❑ J r� l ; PUMP INSTALLATION,.I� SYSTEM REPAIR ❑ OTHER ❑ ** 1 `�, Q` V DISTANCE TO NEAREST: SEPTIC MANIC.. �_SEWER.LINES--.-- F' DISPOSAL-FL-D------�PROP-LINE,--;O FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ",INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO / Industrial ❑ OpenBottonE =p_pAanteca.� , Dia._of:Well_Excavation�-_. ia;of--Well-Casing-44� 2 KID omestic/Private .,,VGravei Pack ❑ Tracy Type of Casing pecifications 3:. ❑ Public`.i �7'Other _❑_Delta Depth of Grout Seal d� --.ter- t, Type of Grout ❑ Ign¢ation. i ppiiix. Depth aster}n Surface Seal Installed by h - Repair-Work Done ❑Type oFump��. S/d HIP. ! 4 Z State Work Done ' Well Destruction ❑; Well Diameter L Sealing Material itop 50'} �• i Depths iH�iC� t filler Materia! (Below 501 TYPE OF SEPTIC WORK: NENNSTALLATION B—REPAIWADDITION ❑ DESTRUCTION ❑ (No,septic,system permitted if public sewer is available:within_200 feet.), I Installation will serve: j'Residence_ Commercial i— Other: Number of living unit r G Num /of A�i-,edrrooms Character of soil to a'depth of 3 feet;,. i _Water table depth i SEPTIC TANK {n TypeYMfg Lr Capacity No. Compartments PKG. TREATMENT PLT. ❑ �' f 1 Method of Disposal Distance to nearest: Well-' i Founda#ion Property Line LEACHING LINE ❑ No. & Length ofli es`^�`+ n �a��f Total length/size e1113� , 1- FILTER BED ❑ Distance to nearest: Well fiointlation Property Line SEEPAGE PITS Ll Depth 3, Size a V, �x Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS iii ❑ 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 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- tion laws of California." The applican I r al d inspections. Complete drawing on r ers ci-d�e. p s y Signed XTitle: d Date: O / DEPARTMENT USE ONLY p Application Accepted b O`i JW --Area p y �-%�' �fl� 7- %k A—�� . Date { Pit or Grout Inspection by Date a Final Inspection by�, Date 22 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-MM Applicant-.Return all copies to: Environmental Health Permit/Services 1,601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO11 OUNT DUE AMOUNT REMITTED ASR RECEIVED BY DATE PERMIT•NO. + EH 13-24 IREY.1/e 51 tr�.� -ter'^ p r•ti r, ~�S�'`® �I EH 14-28 _ 1-G L`-'ti 0.7 ^�+�j Z{