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APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL,HEALTH DISTRICT i 1601 E. HAZELTON AVE.,,STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEARTROM DATE ISSUED .. 1 *. ,SComplete in Triplicate) _ t 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. " " Job Address �oS C� -e City. Lot Size PM Owner's"Name i ti Address Phone I Contractor TA �zULL�rAddress E`C> License No. Phone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ OESTRUC ION ❑ -'PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ t OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.� PROP. LINE L FOUNDATION AGRICULTURE WEL�. bTfiER.WELL L-!• PITS/SUMPS O INTENDED USE t TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ' ❑ Industrialff Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private 17 Gra)e6 Pa r• ❑ Tracy Type of Casing ? � Specifications i ❑ Public ❑ Other y. EJ Delta Depth of Grout Seal # Type of Grout ❑ Irrigations ---Approx.::Depth ❑ Eastern Surface Seal.lnstalled by Repair Work,Done ❑ Type of Pump H.P. State Work pone t Well Destruction ❑ Well Diameter'{{ Sealing Material atop 501 t' p Depth 't Filler Material (Below 501 '' TYPE OF SEPTIC WORK: NEW INSTALLATION §1 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) , ,�. Installatio t+nrill serve; Residence Commercial— T they Number of living units: Number ofedr6otlas Character Df soil to a depth of 3 feet: O i5z t Water table depth SEPTIC TANK ❑ Type/Mfg �^ ► Capacity No +Compartments NZ PKC. TREATMENT PLT. ❑ r Method`of Disposal _ Distance to nearest: Well Foundation Property Line f_ LEACHING LINE , �. No"s& Length of lines � � iTo_tta—l length/size FILTER BEDi Foundation Property L,;'int e s . W1,1., .� stancSEEPAGE PITS 0 z Depth �if313 Size Lp �rNuumber - SUMPSDistance torma�st ry"..61Foundation Property Lne DISPOSAL PONDS ❑I, i ''I I hereby certify that I have .re ared this application and that the work will be done in accordance with San JbBquin county ordinances, state laws, and } rules and regulations of the S n Joaquin Local:Health District. .. Home owner or licensed agent's signature.cerilfies the folio wing:_l_certifyshat.in.the-pe o fnance of the work.for which this permit is issued, I shall not - employ any person in such manner astt—c h dome subject to workman's compensationlayrsAf California." Contiactor's hiring or sub-contracting signature certifies the following:"I certify that in the�p "ormance of the^work for-which thio permit is 6sued, I shall emp,14,pe'rsons subject to workman's compensa- tion laws of;California." ## I A4 I S TM k The applicant must call for"all r ired.' pectin Complete drawing on reverse side { f lkSigned X z t Title: {s date: 1 ! I FOR DIEPARTMENT V$E"OTILY _ 3 f ( a n Acce ted b -- Date Area Application p y - PP � - Pit or Grout',Inspection by 1 a Date - EiriaCTnspection by Date 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 Awe-, P.O: Box 2009 Stk.; CA 95201 f' FEE Y,,AM04JN�DUES - - - A#OUNT REMITTED CK# RECEIVED BYrDA E wPERMiT NO. I(+YFO CASH f.EH-13.24-IAEV.i1.R.sY - __�. -0..--G C�..__.. ZS ��1f7 1 05 r ' EH 1428