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z »,rt APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t-�T zeECDeI� (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 m compliance wilt,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 Address ��+�G S �G x�NL- City F C Lot Size /Y<- PM Owner's Name Address � 303 P/}!,=4s4 jr A- uAJ SIA- Ohone '+��3,,�f 9�'f Contractor __FL e2— Address License No. 1--)-746 Phone _ 3y71 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LI 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 Cl Open Bottom F1 Manteca Dia. of Well Excavation_ _ Dia. of Well Casing ❑ Domestic/Private LI Gravel Pack Cl Tracy Type of Casing------- Specifications I'1 Public I 1 Other I 1 Delta Depth of Grout Seal Type of Grout -_ 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 I I Well Diameter Sealing Material (top 50') J Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.( Installation will serve: Residence Commercial_ Other _._ Number of living units: /_ Number of bedrooms_3 l j Character of soil to a depth of 3 feet: S A Alp —Water table depth __ SEPTIC TANK (•T Type/Mfg C Ct- -PVU'- Capacity l Z� _- No. Compartments PKG. TREATMENT PLT. [ 1 Method of Disposal -- - - Distance to nearest: Well _� Foundation _-Lt2 _ Property Line /O -- / — LEACHING LINE I`1�No. & Length of lines .__,�=_7d Total length/size Z O / FILTER BED I 1 Distance to nearest: Well L7 Foundation I S Property Line SEEPAGE PITS 1 1 Depth Size Number SUMPS I I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Il 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 call for all required inspections. Complete drawing on reverse sidle... Signed X....__ �� ze-h� Title: ( ` - Date: r Z- OR DEPARTMENT USE ONLY Application Accepted by . I fte.0, 6A A Date - Area Pit or Grout Inspection by Date Final Inspection by Date -/a/y 2 -7a.>cl< �t ��C- L� :� � S� -Ire !c -o!c Additional Comments: !? -,� ❑ Stk 466-6781 U Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Se 1 1 E. zelto Ave., P.O. Box k., C 52 ery 1 FEE OUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO IM CASH n �f �Q i EH 1371 fREV.inbl D ('�, (✓ J {� �] /' /1 -AO - / EN 14.7e (((/// (�,