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APPLICATION yFOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i. 1601 E. HAZELTON AVE., STOCKTON, ICA 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 apermit 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 Nd:1862 for well/pump and the Rules and Regulations of the San Joaquin , Local Health District. Job Addressi � � City�L / ..t,Size PM 6LPOwner's Name dress 3&1►•N.Q Phone F Contractor Address 100.r-6AIZ4192i License No.32 f Phone TYPE OF'WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ IIIfFOUNDATION AGRICULTURE WELL AIR'❑ P O "OTHER ❑ I .DISTANCE TO NEAREST:.SEPTIC TANK. SEWER LINES. ' DISPOSAL FLD. PROP. LINE , PUMP INSTALLATION❑ SYSTEM REP 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 i,.,,._,, ❑ Domestic/Private ❑,Gravel Pack _ ❑ Tracy Type of Casing Specifications ;VI Public 171'Other ❑ 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 _ W ( Well Destruction ❑ Well Diameter Sealing Material Itop 501 f i - Depth Filler Material lBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I.I -REPAIR/ADDITION DESTRUCTION 1 1'I (No septic stem permitted it pub • t•- -- _ P system sewer is INSTALLATION, within 200 feed! Installation will serve: _ Residence,. Commercial ther W Number of living units: �'. Number of bedrooms available t^- " Character of soil to a depth of 3 feet: A - Water table depth', SEPTIC.TANK __. ❑-,..Type/Mf9 rz Ce acit - Z� P y ,;No. Compartments s PKG. TREATMENT PLT. ❑ Method of Disposal I......_. ..i ... .. .... _. _ :Distance to nearest; � Well foundation (Property Line ( i !LEACHING LINE No. & Length of lines Total length/size /11 ._--i FILTER BED ❑ Distance to nearestWell Foundation,- Property Line_ - -" SEEPAGE PITS, 1 I, Depth Size i Number SUMPS !;1 Distance to nearest: Well `Foundation Property Line t DISPOSAL certify tht I have.prepared this application and that the PONDS ❑ PP 1,Iit hereby work will be done in accordance with San Joaquin county o{dinances, state laws, and lr ules and regulations of the San Joaquin Local Health D3tnct. I , Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this fiarmit is issued, I shall not ! employ any person in such manneras to become subject to workman's compensation laws of California."Contractors hiring a sub-contracting signature � certifies the Calify pe p 0 'p hall employ persons subject to workman's compensa- �'^-•noo laws of Califorma."t - � � . .. following: "1lcertif that in the performance of the work for which this permit is issue 15 The applicant must call or all requirgd inspections. Complete drawing on reverse side. _Signed X Title: 1 Date: l. -_. J~ ///•• .�11 FOR DEPARTMENT]USE ONLY i Apylication Accepted bY, ��`�� . II Dale \ A ea i Pit or Grout.Inspection y _ - ! pection b Date Final Inspection by Date Additional Comments: '` I { i.—..-❑ Stk- 466-6781-_._._❑ Lodi_.369.3621 C1 Manteca 8237106..... ......0.Tracy._835-6385. i.._._...- _--..- . _ A j` ox 2009, Stk., CA 9520 AMOUNT DUE' AMOUNT-REMITTED RECEIVED BY pp scant - Return copies to: Environmental Perms[/Semces 1601E Hazelton Ave.,Ave, P.O, INFO ASH -- DATE --PERMIT NO. fi.�EH O24 IREV.1/x51 EH 14Ie