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^" v 00 A _'!�? APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ( 1601 E. HAZELTON AVE., STOCKTON, CA 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. il -�_ Lot Size Z,, y Q� PM Job Address T � � �G� ,�L-__1_,�-" — city Owner's Name' �IG� euaA!�2f A Address Phone Contractor D 1's MOOD Address 1OOS"�t/• L+�1-LJ%y ✓ /�l/Lice?rse-N`o:YSY7G Phone_ i TYPE OF WELL/PUMP:}NEW WELL,E] WELL REPLACEMENT 11DESTRUCTION CI drl P^UMP INSTALLATION'O SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK "— SEWER LINES DISPOSAL FLD.__ PROP. LINE AGRICULTURE WELL OTHER WELL PITS/SUMPS Dia. of Welt Casing Specifications Type of Grout JYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitt IF ,Installation will serve: Residence' � Comamercial _ Other LNumber of living units: ;.—Number of bedrooms rCharacter-of-.soil ,to a,depth of -3 feet: SEPTIC TANK M ❑'7ype)Mfg 15 Capacity— - available within 200 feet -I No. Compartments - Method of Disposal 97 public sewer is m PKG. TREATMENT PLT. L r l` Distance of .nearest: Well _ Foundation Property Line f LEACHING LINE L-Xo" &'Length of lines ..._ d Total length/sized X - FILTER/BED rl Distance to rest: Well _�Foundation ._..�— Property Line - J SEEPAGE PITS _t" Depth � 5r r —Size .3 3 _ Number ,.,. r . ,Y �6 , G Distance to"nearest,— 'Well'::JO.0 Foundation _��_. Property Line DISPOSAL PONDS C 1 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 Sen Joaquin Local Health District" 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 46iect to workman's compensation laws of Califorra." 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for /all required inspections. Complete drawing on reverse side_ Signed xe_ Title: Date: 7--i o FOR EPARTMENT USE ONLY Application Accepted by Date tAre, 0 �Q Pit Grout Inspection by _ _ . nal Inspection by Date Additional Comments: ` t - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Envirorimental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 is �* 4 EH 13-24 iREV. i'CS: r EH 1 4.26 FEE AMOUNT DUE 1 AMOUNT REMITTED CASH RECEIVED BYRaPERMIT'NO. INFO FOUNDATION _. INTENDED USE /1 TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS Li Industrial C Open Bottom__! , C Manteca Dia. of Well Excavation U Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casino ❑ Public ,It CI Other . _ L7. Delta. _ Depth of Grout Seal El irrigation `. %., r _. ?Approx. Depth -I Eastem Surface Seal Installed by Repair Work Done D Type of Pump _— H.P. __ State Work Done _ Well Destruction ❑ WeII,Diametert _ Sealing Material (top 501 _ f Depth _ 1_ _ _ Filler Material (Below 50') Dia. of Welt Casing Specifications Type of Grout JYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitt IF ,Installation will serve: Residence' � Comamercial _ Other LNumber of living units: ;.—Number of bedrooms rCharacter-of-.soil ,to a,depth of -3 feet: SEPTIC TANK M ❑'7ype)Mfg 15 Capacity— - available within 200 feet -I No. Compartments - Method of Disposal 97 public sewer is m PKG. TREATMENT PLT. L r l` Distance of .nearest: Well _ Foundation Property Line f LEACHING LINE L-Xo" &'Length of lines ..._ d Total length/sized X - FILTER/BED rl Distance to rest: Well _�Foundation ._..�— Property Line - J SEEPAGE PITS _t" Depth � 5r r —Size .3 3 _ Number ,.,. r . ,Y �6 , G Distance to"nearest,— 'Well'::JO.0 Foundation _��_. Property Line DISPOSAL PONDS C 1 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 Sen Joaquin Local Health District" 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 46iect to workman's compensation laws of Califorra." 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for /all required inspections. Complete drawing on reverse side_ Signed xe_ Title: Date: 7--i o FOR EPARTMENT USE ONLY Application Accepted by Date tAre, 0 �Q Pit Grout Inspection by _ _ . nal Inspection by Date Additional Comments: ` t - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Envirorimental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 is �* 4 EH 13-24 iREV. i'CS: r EH 1 4.26 FEE AMOUNT DUE 1 AMOUNT REMITTED CASH RECEIVED BYRaPERMIT'NO. INFO