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3 APPLICATION FOR PERMIT N " SAN JOAQUIN LOCAL HEALTH DISTRICT C 1601 E. HAZE T ON AVE., STOCKTON, CA ` Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED !I (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. + 7 3 / q33 A935 . 37 3 �7 1N�12� Job Address t J r I ff r City Lot Sizea , Phone 'D�PM CC 1 `l �id r J,Ib tp1�1 tu Owner's Name)�m ��►�� S� 1 Address p �j t Contractor\a), ktt h'f'L 1'. Address s CL License-No. 4 wc' / Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ --PUMPINSTALLATION ❑ ~' SYSTEM REPAIR ❑ - __-OTHER•❑:.. , DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �1�3 �iFOUNDATION'.' AGRICULTURE WELL OTHER WELL {PITS/SUMPS INTENDED USE TYPE OF WELL --'PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 Y' LJ `~^"--'❑ Industrial Op-6n B n ottom ❑ Manteca Dia. of Well Excavation .,,...Dia..-.Dia.. Casing: 7 (� ❑ Domestic./Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I M Public ( :C7 Ot'ier,' - f n Delta Depth of Grout Seal ' r a+Type of Grout — I 1 Irrigation Approxi-Dept l I Eastern Surface Seal Installed by '^ - -.Repair-Work Done ❑—Type.-of Pump------•- ----,-H.P— ---------State Work Done-= -- T-{ 11 Well Destruction ❑ Well Diameter Sealing Material (top 50'1. Depth Filler Ma erial (Below 501i TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION {.l DESTRUCTIO septic system permitted it public sewer is W vailable within 200 feet.)7— Installation will serve: Residence_ Commercial__ Other Number of living units. t 6rn6er of bedrooms Character of soil to a depth of 3 feet: +-- - - - Water table depth SEPTIC TANK CEJ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O t y - YMethod of Disposal . Distance to nearest: Well Foundation Property Line`. f tEACHING LINE 0 No. & Length of lines Totat length/size k FILTER BED EJ Distance to nearest: Well --Foundation Property Line # SEEPAGE PITS ('.I Depth Size Number SUMPIS Ll Distance to nearest: Well Foundation Property Line 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 regulatlons of the San'Joaquin Local Health District. # _ ' Homeowner oraicensed-agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not s employ any parson in sucfi+nanner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature cerS4e's 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 la f California.' � .:_� The applican t call far II re red pecUnscrn-plete drawing on r versa side t Sign Title: P Date: y t ' FOR DEPARTMENT USE ONLY Applkcation Accepted by r j Date— ^_ -._ Area ' Pit or Grout Inspection by t Date ' Y Final rinspection by �ct [ `� (w) Date Q � j Additional Comments: " r '` _ F t'iL O ❑ Stv 466-67810 Lodi nl 369-3621 .t if'❑ 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 I: 'INFE "`AMOIJIVT Dt7E ""4MOUNT REMITTED " " '42 OASR'"'t ,RECEIVED BY DATE" PERMlT'N0 ..EH13-24(Fit V.I/A5 EH 14-M to v i