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APPLICATION FOR PERMIT r . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 ,E. HAZEL T ON AVE.,,STOCKT_ON, CA Telephone (209) 466-6781 ti PERMIT EXPIRES 1 YEAR FROM DATE ISSUED :;;,•= Y •(Com_plete in Triplicate) :_. - �-�.> U __._.. . ---y--race to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This applica t. 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. ' J" .. j `r✓ +u ' Jr Y Job Address J 'U— � P#1 ,•�, s'.... Y.3d 4 y City• Lot Size PM Owner's'Name �//J`'l�2 -mess �� Phone T - Contractor -_Address __ License No. Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ k"SYSTEM REPAIR O OTHER O 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 O Gravel Pack ❑ Tracy Type of Casing_ Specifications ❑ Public O Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation , ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done e❑ Type of Pump H.P. State Work Done ✓�� Well Destruction ❑ Well Diameter Sealing Material Stop 50') r; Depth Filler Material (Below 50') (\� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑. DESTRUCTION (No septic system permitted if public sewer is available within 200 feet:) Installation will serve: Residence____ Commercial_ Other ` 1 Number of living units: Number of bedrooms / € Character of soil to a depth of 3 feet: Water table depth \ SEPTIC TANK e ❑ Type/Mfg I Capacity No. Compartments' PKG. TREATMENT PLT.'O t I Method of Disposal' C $ Distance to nearest: Well- —Foundation Property Line C t ► 4. I LEACHING LINE ; ❑.. No. & Length of lines-=. .__ '` {` tI + Total length/size F p FILTER BED O Distance to nearest: i Well + Foundation 1 t Property Line SEEPAGE PITS ; ❑ Depth Size Number '^ SUMPS i ❑ Distance to nearest: Well s Foundation S Property Line DISPOSAL PONDS" O 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 foNowin6:"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•wbrkman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the fopowing:"I certffor y`that in the perfmance 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 side- Signed:� c �_ -C L O� Title: � �—i^- --- Qats! i OR DEPARTMENT USE ONLY Application Accepted by DateArea_ Pit or Grout Inspection by r Date FinInspection b p 6 , d Tonal Comments: 0 ' ry AStk 466-6781 . ❑ Lodi 369-3621 C1Manteca 823-7104 El Tracy 835-6385 A licant- Return`.all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA.95201 INFO AMOUNT DUE AMOUNT REMITTED # RECEIVED BY ' DATE PERMIT'N0. + EN 13-24(HEV.t:8•5 ••••-r•rT (J�� }� / p�,� I EH 1426; V AV 12—ZITF U�'�/ZZ7