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,I APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 Rules and Regulations of the San Joaquin Local Health District. a li Job Address ��(,A,n�1 a N City 7ar�Gy mm� Lot Size PM Owner's Name ` 1 �'P�'' Address 01 1: Phone`Fl 6:546{-9CX5 1 K _ Contractor" Address - - "5 F, License No. - TYPE ..,s ca OF WELL/PUMP: �� WEL - EPLA ENT ❑ I 1 Etiu.�..vrss �,,,,,�.;,� DESTRUCTION © PUMP INSTALLATION ❑ VYSTEM REPAIR ❑ OTHER,)R1 (2EorrEc.Ht,sICALYR\, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS S INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS q Ll Industrial Q Open Bottom ❑ Manteca Dia. of Well Excavation {r.! Dia. of Well Casing ' ❑ Domestic/Private ❑ Gravel PackTracy Type of Casing Specifications I'1 Public Cl Orhert n Delta Depth of ;t 5b '�O Type of Groutr I I irrigation --Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material itop 50') „ Depth Filler Material (Below 50') —4- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I ] DESTRUCTtONII INa septic system permitted if public sewer is available within 200 feet.) 3 Installation will serve: Residence_ Commercial Other [n Number of living units: Number of bedrooms Character-of soil to a depth of 3 feet: Water table depth Q� SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments + PKG. TREATMENT PLT. © Method of Disposal Distance to neatest: Well Foundation Property Line n LEACHING LINE ❑ No. & Length of lines Total length/size ! FILTER BED I 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITSI I Depth Size Number jj SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 applicant must c 11 fo requi nspections. Complete drawing on reverse side. Signed Title: _6mINET Date: 2 F DEPARTMENT USE ONLY I' n b / Application Accepted by - Data Area Pit Grou Inspection b - Date , �y Final Inspection �� Date&~�� �� I: Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 t Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 l ( II FEE AMOUNT DUEAM r OUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CASH EN 13-24 7c -241REV.tiN5l �/ y(,(�r�J /fin /%� �jq0_)0c EH 144.20 �(JJ �j y f•• �( b l i