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APPLICATION FOR PERMIT SAN JOAO.UIN 'LOCAL HEALTH DISTRICT N i { 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 `P 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.This application is made in compliance with San Joaquin County Ordinance No.549-for sewage or No. 1862 for well/pump and the Ryles and Regulations of the Sart Joaquin Local Health District. Job Address �r' " f a��1 ` City Lot Size �Q VK3 PM VY Owner's Name Address- Phone F36 - /� t Contractor i/ •' Address_ �? � License No. f Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications " ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by r Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public.sewer is ;4 available within 200 feet.) ro ! Installation wiil-serve:. Residence_ Commercial Other a r_ 1 )IS, Number of living units: Number of bedroomsCharacter of soil to a depth of 3 feet: Water table depth PTIC TANK Type/Mfg Q Capacity—/- No. Compartments + PKG. TREATMENT PLT. ❑ J - I Method of Dispolal Distance to nearest: Well Foundation Jf! Property Line 100 t f st `-- LEACHING LINE Cl No. & Length of@nes Total length/size FILTER BED ❑ Distance to nearest:' N Well Foundation Property Line o o �r f SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well 1- 1661ndation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work-will be donb,in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. r- ' Home owner or licensed agent's signature certifies the following: "I certif 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 compensaiion Iaws4dCalifornia."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 Califomi The applicant t I.for req., in etiow . Complete drawing on r rse side. •r / k / 'N • SignedS Titie: Date: FOR DEPARTMENT USE ON gY i Application Accepted by ,C/ "" '+- '"'" �` Date Area NJ�cJ s£P77 G i✓6-4,0_�uT Pit or Grout Inspection by / Date Final Inspectionn-by rV r4u,e�a �� Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy8364W i Applicant- Return all copies to: Environmental Pealth Permit/Services 6001 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4- .3113 1 d .- ll�-+rti�!!<.d / ...�c, c' �1 .-r/ ux- �e�.-r�-r�(� �`� +�^ca•gid �-F ✓e sr FEE _ MITTED RECEIVED BY DATE. PERMIT`NO. ,INFO AMOUNT E]VE AMOUNT -- _ :_.GASH.,-;,_. _ .,�_ _ - ..�- --- z�:. *, t T � t. r"° S.S7:ii V Vis. rez + EH 73241r1EV.1/851 a �O / LN EH 1426 yr' # �+.. - �A'C19 S