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.. _ APPLICATION FOR PERMIT i c SAN JOAQUIN LOCAL HEALTH. DISTRICT . 1601 E. 1`A' ELTON AQt., STOCKTON, CA 09 466 6781 Telephone I2 1 - 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. J ] d Job Address '�` S�C1J�{ City 1 Lot Size PM Owner's Name Address AO A y-1 -70 - Phone /V — f 7� / ii/li , Address �l� C,��License No. l Phone Contractor =� - TYPE OF WELL/PUMP: DISTANCE TO NEAREST: INTENDED USE Cl Industrial XDomestic/ Private M Public I 1 Irrigation Repair Work Done Well Destruction d■ NEW WELL 'sv` WELL-"-REPL'Ao-CEMET11 'U' tato i PUMP INSTALLATION I ` SYSTEM REPAIR ❑ SEPTIC TANK I6e*4 SEWER LINES �� DISPOSAL FLO FOUNDATION �r AGRICULTURE WELL OTHER WELL TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ravel Pack ❑ Tracy Type of Casing n Other ❑ Delta Depth of Grout Seal ol�-Approx. Depth��--MS�I 1)�Castern -1 S`u rf a Seal Inst_allod`by Type of Pump X2 00 H.P. �J '�` f State Work Done Well Diameter Sealing Materiiaal..ltop 501 Depth Filler Mate',at 'iBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLA N I:I N ❑ R ❑ f � PROP. LINE S'117� PITS/SUMPS mor 43 Di of Well Casing PEP AIRIADDITION I I DESTRUCTION I I (No septic system permitted if public available within 200 feet'.) Installation will serve: Residence + Commercial_ .Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth _ SEPTIC TANK ❑,. Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Methoddf Disposal Distance to nearest: Well Foundation Property Line a 'er is' ' �y C LEACHING LINE Cl No. &'Length of lines Total length/size FILTER BED ❑ I Distance to nearest: Welt-- ---Fpundation Property Line SEEPAGE PITS l I Depth , Size _ Number SUMPS ❑ Distance to nearest: Well . Foundation Property Line nrconcei onnrnc F-1 I hereby certify that I have prepared this application and that the work will be done in accordancewithSan 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 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." The applican s gr II requir ns. Complete drawing on rev rs@side. Q Signed X it e: Date: «S� FOR EPARTMENT USE -O LY ^ \' \ Date Area J Application Accepted by v� Pit or Grout Inspection by Date �/ Final Inspection by Date /o r ' Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/ Services 1601 E. Hazelton Ave., P.0 1 r. EH 13-24 IREV. I/ N 5 EH 14-26 Box 2009, Stk., CA 95201 FEE AMOUNT DUE INFO AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT' No. 10�,'d