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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT --- 1601 E. HAZEL T ON AVE., STOCKTON, CA 1 Dpi Telephone (209) 466-6781 ! [PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r, {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 r w -Local Health District. r r 11 r } d 1 e � Jbb Address 1I ®& I I� :Sa City r Lot Size PM j Owner's Name r J 1 1 r,7E k y�lln P I�2 f Address f 1 c9&2 � �,,1 L 1240 e P S i r 214 Phone 1 [] Contractor 1/1,116 1Zti A A Address / -l .A6 CL License Nos -g9-3al Phone . j '"""""----TYPE OF WELL/PUMP:- - NEW WELL ❑- DESTRUCTION } PUMP INSTALLATION 0. SYSTEM REPAIR ❑ OTHER ❑� y DISTANCE TO NEAREST: SEPTIC TANK Sf� ' SEWER LINES DISPOSAL FLD. PROP. LINE ." 4 z FOUNDATION AGRICULTURE WELL OTHER WELL_ PITS/SUMPSI4 r ar INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial XOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pac ❑ Tracy Type of CasingS�C'G` Specifications 8 ❑ Public ❑ Other I Cl Delta Depth of Grout Seal r Type o Grqut I f Irrigation 3oc2.-02 -Depth I Eastern r urface Seal Installed by 1 _ Repair Work Done ❑ Type of Pump H.P. ZPL o State.Work�Done Well Destruction Y Well Diameter Tt, Sealing Material,>>,� Depth /ea�d r Filler Material+BeteB9 :5� dq k% TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION 1.1 DESTRUCTION I I (No septic system permitted if public sewer is � t ' available within 200 feet.) t Installation will serve: Residence_ Commercial—, Other `Number of living units: - Number of-bedrooms "` m - -- -�--- t i r Character of soil to a depth of 3 feet: Water table depth I """'SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments u A1PKG. TREATMENT PLT. ❑ Method of Disposal + r —Distance to nearest; Well Foundation Property Line LEACHING LINE' ❑: No. & Length of lines Total length/size FILTER BED y ", r❑ Distance to nearest: 'Well Foundation Property Line SEEPAGE PITS r i V] Depth Size Number , SUMPS }_ _! 'Cl Distance to nearest:" Well Foundation Property Line ' bISPOSAL PONDS ❑ t 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 Diltricf. +�s -Home owner or licensed agent's signature certifies the following: "I certify that in the performance.of tFie wbrk 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 California." :'II The applicant must call for all required inspections. Complete drawing own*reverse side. J �� a �C7, � t Signe X /3L►T` ;:I li A�dOns. Title: �J�'G/V C-5 _" Date: a ti FOR DEPARTMENT,USE.ONLY, Application Accepted by Date �+[ / Area v , Pit or Grout Inspection b I/l/L Date -t' Z r Final In pec( b ' Date' Additional Comments: dt- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 923-71 racy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE f AMOUNT REMITTED CK if CASH RECEIVED BY DATE PEtlMl 'Iwd,