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` APPLICATION FOR PERMIT �^ SAN JOAaUfN LOCAL HEALTH DISTRICT _ 1601 E. HAZELTON AVE., STOCKTON, CALf�"' 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. T� Job Address S f City �r✓� Lot Size PM Owner's Name(�, Q`rT C� L."_F 400—I IF Address —_ �/7 _ Phone Contractor License No., 7-7q-4-Vnone TYPE OF WELL/PUMP: NEW WEL V1/ LL REPLACEMENT ❑ DESTRUCTION ❑ PUMP IN,< LATI N SYSTEM REPAIR OL' �� OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Welt Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications nn Q Public / ❑ Other ❑ Delta_ Depth of Grout Seal Type of Grout 1 ❑ IrrigatiarY f �l/� ___-i�pprox. Depth ❑ Eastern Su ace Seal Installed by Repair Work Done J❑ Type of Pump. H.P. State Work Done Weil Destruction ❑ Well Diametr e I Sealing Mate a] (top 5U'1 - Depth Filler Material {Below 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is .4" " —; available within 200 feet.) Installation will serve: Residence Commercial_ Other Q Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK i ❑ Type/Mfg Capacity No. Compartments ` PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE �4 ? ❑ No. & Length of lines Total length/size FILTER BED j ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to clearest: Well Foundation Property Line DISPOSAL PONDS . / i❑ 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: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person7n such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature certifies the fall wing: "I certi that i the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of C for, ) The applicantAust ell for Arinhsons. Complete drawing on reverse side.. Signed Title: �{ Date: i FOR QEP RTMENT USE ONLY Application Acce ted bye Date Area _ .4- Pit 4 Pit or Grout Inspection by,:. Date Final Inspection by^ v!�d?� `- Date�_a Additional Comments: ❑ Stk 466-6781 Lodi 369.362 ❑ Manteca 823-7104 ❑ Tracy 835-8385 —Applicant.-Return al(4)09 to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FEE INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY I l DATE PERMIT'NO + EH 13-24(REV.i/a5) 3 y• �1(, � O y.�3�..}�/„ �A—Zfj EH 1428 'V�J / u c� `�Vf i _J