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APPLICATION FOR PERMIT CEI VE r4j SAN JOAQUIN LOCAL HEALTH DISTRICT 2 �" „ 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 NOV 2 p 1� PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDI�/j�p� I`�r�$� �.��:° PERMIT/SER Vrf , 11..., (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 welllpump and the Rules and Regulations of the San Joaquin Local Health District. ( i Job Address lLAC[a 1 I Y � Edi City �w I Lot Size PM Owner's Name Address f q COntracto l Address V-0.&1C f� ( _License No. z z Phon "S[0 TYPE OF WELT-/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 F Public ❑ Other 1-1 Delta Depth of Grout Sea! Type of Grout I 1 Irrigation T_Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION {1 EPAIRIADDITION DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Resi nce Commercial 0th r Number of living units: Number o edrooms 'bD- p��LdLRyQ L,�QJLId Character of soil to a depth of 3 feet: Water table depth U0 SEPTIC TANK A Type/Mfgr Capacity No. Compartments 19 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation ( Property Line / r LEACHING LINE No. & Length of lines Total length/size 0 r FILTER BED E) Distance to nearest: Well�� Foundation�_ Property Line SEEPAGE PITS Depth Size Xz ld Number Y SUMPS Distance to nearest: Well 0�oQ Foundation --/Q Property Line —_5 - - r DISPOSAL PONDS ❑ I hereby certify that l 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 Joaquin Local Health Di§trict. Home 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 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's 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 applica st cal{toinspections. Complete drawing on reverse Signed X Title:_ - . Date: 1 l i.(r� 9y OR DEPARTMENT USE ONLY / �y pptication Accepted by11A7 Date_//� % AreayZ 1 G out Inspection by Data 9� Final Inspection by L 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. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. ^� + Eli 13-24(REV.1?R5) y�� C ci Ahry EH 14-28 nit VV 'V O