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v f APPLICATION FOR PERMIT y y 5 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA �k Telephone (209) 46&-R$1— PERMIT EXPIRES TYEA•R FROM DATE ISSUED r (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. I Job Address r City Lot Size PM I R J� 7<7e/ Owner's Name �YL dress Phone 0 r Contracto r Z��LAddress ese No Phone TYPE OF W LOP MP: NEW WELL ❑ VVEI L REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR LJ 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack. ❑ Tracy Type of Casing Specifications M Public f_1 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx-Depth t-l-Eastern -' �.»-SurfaceSeal-Installed by r Repair Work Done ❑ Type of Pump 1 H.P. State Work Done _ Well Destruction, ,❑ Well Diameter fi ealing Material (top 501 Depth L Filler Material (Below 50`) { TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTION l I (No septic system permitted if public sewer is k available within 200 feet.) Installation will serve: Residence 1 Commercial_ Other , Number.'of living units: Number of bedrooms It i° Character of soil to a depth of 3 fee"t;.a I Water table depth SEPTIC TANK [ Type/Mfg - - - - - Ga ��r No. Compartments PKG. TREATMENT PLT. ❑ Method of Di osaI ' 7 'd- Distance to nearest: Well 1 do Foundation Property Line LEACHING LINE l�l� No. & Length of liries Total length/size FILTER BED ❑ Distance to nearest:: Well Foundation Property Line (� SEEPAGE PITS YI Depth Size 46 Number SUMPS ❑ Distance to nearest: Well Foundation S� 0-1 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, an rules and regulations of the San Joaquiri Local Health Diltrict. Nome owner or licensed agent's signaturecertifies the tollowing: "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." Contractors 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 m t all. re d 'r pecti . Complete dr on reverse side. Signed X e, ' `Date: FO EPARTMENT USE ONLY Application Accepted by Date '� Area it- r Grout Inspection by Date / Final Inspection b Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,.P:O. Box 2009, Stk., CA 95201 r FEE INFO AMOUNT DUE AMOUNT REMITTED CARR RECEIVED BY DATE PERMIT NO. a.EH 13-26rFEV.rie5) 9� 3 I EH 11-2e / "( I