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" I 1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT j 00 ��y 1601 E. HAZEL T ON•AVE., STOCKTON, CA _ 3 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED s, (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. p t Job Address r ��— � i &-I-e ILA ' City Lot Size 3520 11C PM lf' 4 AddressQPhone ?--s �— `i 6 Owner-'s i :Nam, 1 Contracto*� rs N me License No. 4 3 9 X2 _ Phone �'1�^21 _ _.- r . _ - v_ -- TYPE OF WELL/PUMP:; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �� k PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER'El '' _ 1 + � DISTANCE O NEAREST �SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE V '. s S FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r i INTENDED USE ` TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom_Q-Manteca__,e,--Dia. of Well Excavation ,.,,.Dia.-of Well Casing ,, Cl Domestic/Private ❑ Gravel Pack '❑,.Tracy `Type of Casing Specifications V ❑ Public ❑ Otfer b ❑Delta Depth of Grout Seal ` `L.r Type'of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by; � } Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (tap 50'1 i Depth Filler Material iBelow 501 ! TYPE OF SEPTIC WORK: NEW INSTALLATION ❑. REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is N available within 200 feet.) i , x Installation will serve: ResidencN�__ Commercial-* - Other F Number of living units: 'Z— Number of be roo s' ` w t� 1-.....—. Character of soil to a depth of 3 feet: -^a ` Water table depth; . l SEPTIC TANK ❑ Type/Mfg Capacity—'. No?'Compartments PKG. TREATMENT PLT. El (Method of Disposal' Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines ` ` Total length/size , FILTER BED ❑ Distance to nearest: ,Z.Wel Foundation Property Line SEEPAGE PITS ❑ Depth f Size Nufnber �1 SUMPS ?<� Distance's nearest: tl WeI6 ., 47, 6unclatio�n�� Property Line /00 DISPOSAL PONDS ❑ = 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•.cerrttify�at-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 Califor 1a' «� The applicant mu II fo_r all r! uired inspections. Complete.drawing on reverse Signed Title: . Date: T FOR DEPARTMENT USE ONLY Application Accepted by Date Area ` Pit or Grout Inspection byi Date Final Inspection by 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. Hazelton Ave., P.O..Box 2009, Stk., CA 95201 INFO AMOUNT DUE 1 AMOUNT REMITTED CASH RECEIVED BY DATE JEMIT'NO. ' + EH 13-24 MEV.101831 q�� EH 1478 �. +- �•. '('.,�c.?