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+ APPLICATION FOR PERMIT p� `^ SAN J_OAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON A�E,, STOCKTON, CA I 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 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. ' IA PkA i.nmruy cnnny_rnat.,+ aave_preparea tnis appilcatlon and that the work will be ddane_ one in accoro with SJoaquin county -ordinances; state laws, and rules and regulations of the San Joaquin Local Health District. = Home owner or licensed agent's signaturo certifies the following: '9.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-contiacting 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 t ompensa- tion laws of California." , I The applicant o all req ctians. Complete drawing on r ers a. II Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by �- _ GC_ Date" a Area Pit or Grout Ins y 1 �y�,/"�,,/I /�� + r�o Inspection b Date Final Inspection by ?' !!!i� Date 1��1 Additional Comments: ❑ Stk 466-6781 ❑ LodiZ-10-3621❑ 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 t EH 1341 (REV. t EH 1426 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY Owner's Name ' W_ 7 .-dress /OfJ3 ir/J/Y -9T.� Phone— `.'_' Contractor GNAT - Address 1?f 2_f,(1 � License No, Phone TYPE OF WELL/PUMP: _ NEW WELL WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHEP ❑ /+^'7 DISTANCE TO NEAREST: SEPTIC TANK �arD T SEWER LINES DISPOSAL FLD.L-� PROP. LINE Z'O-; �— FOUNDATION %D,� AGRICULTURE WELL. OTHER WELL PIT SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS // A L7 Industrial LJ Open Bottom Cl-Mantecb Dia -.of Well Excavation _. Dia. of Well Casing Domestic/ Private v. ..._ ..�-, &Gravel Pack D. -Tracy Type of Casirig ��G- Specifications%— 'SPS/ f'1 Public f-1 Other LI Delta Depth of .'Grout Seal ✓ t Type of Grout I I Irrigation Z�QApprox. Depth I I Eastern ;. i'. ,Surface Seal Installed byh'l/pJ51�5 Repair Work Done L) Type of Pump �_rl H.P~ 2 State Work, Done 1N611'Destruction ❑ Well Diameter ( Sealing Material (top 50') Depth __ _ .w_ i_,J iller_M44 erial 'IBelow 50') TYPE OF SEPTIC WORK: NEW INSTA I -I REPAIR/ADQITION-H—• • ESTRUC-TION I I (No septic system permitted if public sewer is "• ,JS available within 200 feet.) Installation will serve: Residence .-.. -',CommercialOther Number of living units: .- r 'Number of bedrooms Character of soil to,a depth 6f.,3 feet: a er table I epth.- l SEPTIC TANK r L7; Type/Mfg Cap_a _� _! No. Compartments PKG. TREATMENT PLT: i d-_ Method of Disposal31. if Distance to nearest: _i ndation Property Line LEACHING LINE Lli-No. &%Lof lines ' r _ - _ Total length/size FILTER BED C-]' rs{ance to nearest: --Well----�^�-- 'FoundatioPraperfy Line" - I SEEPAGE PITS I I Dopth Size SUMPS Ll Distance to nearest: Well Foundation DISPOSAL PONDS C) � \ • • ' A I i.nmruy cnnny_rnat.,+ aave_preparea tnis appilcatlon and that the work will be ddane_ one in accoro with SJoaquin county -ordinances; state laws, and rules and regulations of the San Joaquin Local Health District. = Home owner or licensed agent's signaturo certifies the following: '9.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-contiacting 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 t ompensa- tion laws of California." , I The applicant o all req ctians. Complete drawing on r ers a. II Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by �- _ GC_ Date" a Area Pit or Grout Ins y 1 �y�,/"�,,/I /�� + r�o Inspection b Date Final Inspection by ?' !!!i� Date 1��1 Additional Comments: ❑ Stk 466-6781 ❑ LodiZ-10-3621❑ 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 t EH 1341 (REV. t EH 1426 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. V,�