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r - APPLICATION FOR PERMIT �. SAN JOAQUIN,LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,,STOCKT_ON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED / l �. -(Complete in Triplicate) u 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. tr Job Address U— � City._ Lot Size PM Owner's Name 7T /M (�� " / lQrt�ress �� Phone Conlraclor Address. .License_No. Phone_ TYPE OF WELL/PUMP' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C PUMP INSTALLATION n '-SYSTEM REPAIR ❑ OTHER G 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 Ll Industrial Cl Open Bottom CJ Manteca Dia. of Well Excavation Dia- of Well Casing ❑ Domestic/Private U Gravel Pack Cl Tracy Type of Casing__ Specifications i 1 Public ❑ Other Ll Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. __ State Work Done r Well Destruction ❑ Well Diameter _ Sealing Material (top 501 Depth Filler Material (Below 501 ! O\\ TYPE OF SEPTIC WORK: NEW INSTALLATION fl REPAIR/ADDITION U. DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence____ Commorcial_ Other jp1 r" i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: _. ''"'" _._ Water table deptti = �, SEPTIC TANK f ❑ Type/Mfg __ Capacity r No. Compartments A - PKG. TREATMENT PLT,❑ I Method of Disposal___. Distance to nearest: Well- _ —'Foundation 1 Property Line 1 _ ► k. LEACHING LINE ° ,. No. & Length of lines• T�,.—•w• V` El _ Total length/size i FILTER BED ❑ Distance to nearest: / 'Well + Foundations 1 Property Line 1" i � t SEEPAGE PITS ❑ Depth Size Number -_ y SUMPS l n Distance to nearest: . Well ._. Foundation t 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 followin6: "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 r"A ( certifies the following:"I ce`ify 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." ` 1 The applicant must call for allrequired inspections. Complete drawing on reverse side. Signed X �`i(/�l Q�J _._ Title: Da' OR DEPARTMENT USE ONLY t �t Application Accepted by Date 7� � Pit or Grout Inspection by _ Date_ . Fin Inspection b Da�tva d lona/Comments: i /"O Stk 466.6781 Cl Lodi 369-3621 :3 Manteca 823-7104 fl Tracy 835-6385 A licant- Return-all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED tt RECEIVED BY ' DATE PERMIT•NO. EH1 3.24 1REV.t;d.5 J _/////, 1-.'^'*: • _� -. __ —.. /_..�•y� ,. EN 14-29. /V �� ♦� +lZ`�.7' 4•�'�SZ7 ,...