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r APPLICATION FOR PERMIT " ►- SAN JOAQUIN LOCAL HEALTH, DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA k Telephone (209) 466-6781 RMIT 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. 11362 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 7_5 City � /� ! Lot Size PM Owner's Name Z!?4?VjC Address r�� Phone !! C7 • Contractor Zvm Address 7��`(J� } lf`-C�� License No. dz / Phone + t I 1�-_tYPE OF WELL/PUMP: -NEW WELD, ❑ WELL REPLACEM NT ❑ DESTRUCTIO 3 f r ` PUMP INSTALLATION 0 SYSTEM REf AIR ElOTHER ❑ `rL s E tt".,,11i�DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Indus trial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications l\ ❑ Public ❑ Other } H Delta Depth of Grout Seal Type of Grout----- I rout _i !i 1 Irrigation "" -�" 'App�ox. f5epth�-41TEastern urfaceeal'lnstalled'by ,Repair Work Done I D Tye of Pump 1�i.P. A State Work Done �►72��Aezrlp W11,Destruction Well Diampfe,,4 / - $2ea ling Material Itop fa) l DeptlirT ! 6 A e oZ ?^� Filler Material IBeIow/00') TYPE OF SEPTIC WORK:.,NEWMNSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is }� available within 2D0 feet.) I I Installation will serve: Resithq' it Commercial— Other Number of living,units: Number of bedrooms S�Charw�ter of soil,to a depth of 3 feet: -_ f, Water table depth SEPTIC TANKI It ❑ Type/Mfg I pacity.�i No. Compartments f \ .PKG. TREATMENT PLT. ❑ /,--j Method of Disposal . j Distance to nearest: Well Foundations Property Line - �"^) 'LEACHING LINE f ❑ No. & Length of lines {{ 1 �'� � Total length/size f 1 r F LTER BED i ❑ Distance to nearest: Well t FoundatrA Property Line rir SEEPAGE PITS 11 Depth I Size 1 • '7Nmher t s ' •sat a = { c `V�� SU�S � Cl Distance to'nearest: Well � Foundatio "�"" Property tine tl DISPOSAL PONDS EJ II hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate laws, and f rules and regulations of the San Joaquin Local Health Di§trict. t I Horne owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not j employ any person lin such manner as to become subject to workman's compensation laws of California." Contractor's hiringb�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 subj�c�to workman's compensa- `tion laws•of California," The eppl cant ! r 11 req ons. Complete drawing on reverse side. l 5,•. It, ^ a Signed X Title: 4�k Date: 1 1 011 -...- ;. FOR DEPARTMENT USE ONLY Application Accepted by - 1 Date�.__- -2 Area Pit or Grout Inspection by Date Final Inspection by ! Dat -6➢�� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 D Tracy 835-6385 ; Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE- AMOUNT DUE "-" AA710LfNt HENIfT7Et�" "CK R EIVED l3Y"-' ` DATE PERMITN.O, 1 INFO j sCA /r +-EH 1324 IREV.s i x sl �� Ff'g... _ -�j_• - [� �� 1 T '-� , EH 14-26 ti•.•w�-' - iii"' CC!! ' .4