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4 t APPLICATION FOR PERMIT ' ,+ f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I 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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. S�fQ CtI,7Viµ j„(f 44Job Address - /123 '030—0 .., City Lot Size_ PM R MOSS J '/ /J p �.j 9 ii Owner's Name �"/OSSV f/e—JJS34G I-W Address ��O I-7� /'0/0 J�O Phone e frv� t/ f f actor Address0 Z� Phonee��f L Contr � ✓ TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION U PUMP INSTALLATION CU SYSTEM REPAIR U OTHER*A?i9f11Aa 1PJ W 1111f, DISTANCE TO NEAREST: SEPTIC TANK _._ SEWER LINES DISPOSAL FLD. 7� PROP. LINE FOUNDATION! AGRICULTURE WELL &- d' OTHER WFI I PITS/SUMPS/YQ,7G INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFI NS industrial O Open Bottom fel Manteca Dia. of Well Excavation Dia. of Well Casing J Domestic/Private )(-Gravel Pack Tracy Type of Casing YL 0 -Specifications Public - er n Delta Depth of Grout Seal Zo Type of Grou4enelt-emt- Ire �lJs, I Irrivation - r x. Depth i Eastern Surface Seal Installed by Repair Work Done C ype of Pump I H.P. _ ____ State Work Done— Well Destruction Well Diameter f r• Sealing Material (top 50') TO Z0" ` 6'►1` e� arc S�✓��' ■ �� d�. h j��/s Depth :._: 'zC ___ Filler Material (Below 50') elme 7r TYPE OF SEPTIC WORK: NEW INSTALLATION I : RFPAIR/ADDITION . I DESIRUCTION . I (No septic system permitted if public sewer is O I available within 200 feet.) - O Installation will serve: Residence _,.,r/Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I __ __.____________._ Water table depth SEPTIC TANK C TypeiMfg I .. - Capacity No. Compartments PKG. TREATMENT PLT.C Method of Disposal Distance to'nearest: Well __. Foundation Property Line i LEACHING LINE LI No. & Length of lines .____-- Total length/size r , FILTER BED 1 Distance to nearest: Well. Foundation Property Line I SEEPAGE PITS I I Depth I Size __ Number SUMPS D Distance to nearest: Well .—'Foundation Property Line DISPOSAL PONDS L 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 certHy that in tho 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."Contractors hiring of 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 The applicant rst call for all required inspections. Complete drawing on reverse side. u Signed X Title: �/��`dr - Date: ��FOREPARTMENT USE ONLY 9 Application Accepted by Date r / Area Pit or Grout Inspection by Date Final Inspection by e Date Additional Comments: rr Stir 466.6781 ❑ Lodi 369.36211 ❑ Manteca 823.7104 ❑ Tracy 835.6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 FEE fi INFO �AM&UNT DUE I AMOUNT REM�I+T\TED CASH K 9 RECEIVED BY DATE Q 4PERMt7 N0. EM 13.24IREV.r�n t'i ffVV7 ! ! .FH t4-7a 1