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APPLICATION FOR PERMIT po µ.00 b SAN JOAQUIN LOCAL HEALTH DISTRICT _ 1601 E. HAZELTON AVE., STOCKTON, CAS' Telephone (209) 466-6781 y�� y✓�� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is huieby 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. Job Address V JJ161 City Lot Size PM Owner's Namer—LiQ NAS Address1y3 -__ Phone 9,51 w5q2 Contractor Address License No f Phne_715e, TYPE OF WELL/PUMP: NM WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM,REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES r 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 Casin� Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (`t Public F Other CI Delta Depth of'Grout Seal Type of Grout I I Irrigation WApprox. Depth I I Eastern Surface Seal Installed by Repair Work Done L1 Type of Pump H.P. State Work Done G Ly _ ? Well Destruction Well Diameters- - _---Sealing-Material (top_50')_,_ Depth Filler Material (Below 50') V^v TYPE OF SEPTIC WORK: NEW INSTALLATION ('I REPAIR/ADDITION I DESTRUCTION i I (No septic system permitted if public sewer is Vt� _ ' available within 200 feet.) Installation will serve: Residence Commercial Other""'—"" –' Nurr'iber-of living units: Number of bedrooms Characier of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg i Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ' Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Lenl n gth of lines Total length/size � FILTER BED ID Distance to_nearest: Well Foundation Property perty Line SEEPAGE PITS I I Depth Numbed � SUMPS_1 ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 01= 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 Mtrict. , 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 sucfi`mariner as to become subject to workman's compensation laws of'California." Contractor's hiring or sub-contracting signature 1 certifies the follow ng: "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 r N�' y` +-�r The applican call for all requir d inspectio Com late drawing on ev s side. 1 Signed X Title: 1 1 Date: 3 FQ r ARTM USE IDNL Application Accepted by Date C7 . Area Pit or Grout inspection by ; Data Final Inspection byDate 7 iiO Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621: ._ ❑ Manteca_ _523-7104 _ .0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health'Permit/Serv1ces`1601 'E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FENFO E AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +,EH13-24 INEV.1 i H 57 1 [/,y 7 EH 14-26 Or a O `C O' v