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*'" r APPLICATION FOR PERMIT SAN JOAO,U"IN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA k 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 Ryles and Regulations of the San Joaquin Local Health District. '02 k j W7g: F as: Job Address f0City G Lot Size :'PM ,- w:. � ',_� r.y. n5-, �'', . - .a �-.;4 � - "� ,N?'�. .- -,x� .:- o. Y•' Owner's Name 4772— � ^ 1��Address _ - Phone, = - Contractor 19 11 Address ,7 License No. one _.._._,.TYPE OF-WELL/P,UMR., " ""': IVEW_WELC'❑ _ WELL REPLACEMENT ❑ DESTRUCTION ❑,•' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER`Ll DISTANCE TO NEAREST: SEPTIC TANK I _SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL- OTHER,WEIz±L �.._!L PITS/SUMPS +— INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` ❑ Industrial ❑ Open Bottom_ ❑ Manteca Dia. of Well Excavation Dia. of Well Casing � z ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications .E E) Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approz: Depth ❑ Eastern r Surface Seal Installed by I Repair Work Done ❑. Type of Pump H.P. State Work-Done-' Well Destruction ❑ Well Diameter i Sealing Material Itop 50'1 Depth Filler Ma0r418elow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ lNo septic systerfi-permitted.if public sewer is ' I available"-within 200 feet.) Installation will serve: Residence = Commercial O her Number of living units: __L_ Number of bedrooms C aracter of sail to a de th of 3 feet: '+ Water table depth h p SEPTIC TANK < Y",:0 Type/Mfg Capacity l5- L No. Compartments PKG. TREATMENT PLT. ❑ xpr I Method of Disposal Distance=to nearest: Wel!' i s 't, Foundation Property Line LEACHING LINEVo. & Length of lines Total len hlsiie FILTER BED ❑ Distance to nearest: Well Foundation�d Property,Line a SEEPAGE PITS 11 Depth ' wl Size ' .!P� Number SUMPS ❑ Distance to nearest: Wellt�� T-- Fisianda#ion I Property Line DISPOSAL PONDS ❑ E p ;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, and rules and regulations of the San Joaquin Local Health District. # Home owner or licensed agent's signature certifies the following: q I certify that in the performance of the work for which this permit is i ued, I shall not- employ any person in such manner as to become subject to workman's compensation laws of'California."Contractor's hiring orsub contcting 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 workrman's compensa- tion"laws of California." The applicant must call for al equire 'nspections. Complete drawing on reverse side Signed ` ' �" Title Y "� zI � Date: "• ri FOR DEPARTMENT USS ONLY ' i a N i , Application Accepted by 1 Date t ; Pit - i F by Date or Grout Inspection by Date IFinal:Ins Inspection s" Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 WTracy 8355-6385 I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Aver, P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH - .RECEIVED BY DATE PERMIT"Np. INFO EH 13-24(REV.,/",) �✓{� - 1 rr�'-(�' j lb�, EH M26 - , .�.