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APPLICATION FOR PERMIT ��yy,� SAN JOAO:UIN"LOCAL HEALTH DISTRICTPVV A-57 fit-1 1601 E. HAZE T ON AVE., STOCKTON, CA ! h Telephone (209) 466-6781 5 -al , -Co _ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED L-/Y ' S C (,L�lU -ytj: �le..y (Complete in Triplicate) G Com. 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 ON, _} Cit f� �'� l /r� ply ff y Lot Size Owner's Nan)e cLe',N -%GIJw1 ! A;[ ►"ry'�PEd - r - - ' t CC dress ' �t Phone Contractor L J e Address 100 0 IV V w 0.1, License No. � Phone I I 1�l TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ; FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION-SPECIFICATIONS ❑"Industrial;' ❑ Open Bottom ❑"Manteca Dia:of Well Excavation Dia. of Well Casing ❑ Domestic%Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type bf,Grout ❑ Irrigation '--Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work.Done ❑ Type`f Pump H.P. State Work Done_ Well Destruction ❑ Wel! Diameter1't. Sealing Material {top 50') Depth { _ Filler Material.{Below 501 0� TYPE OF SEPTIC WORK: ,NEW INSTALLATION ElREPAIR DDITIO DESTRUCTION !(No septic system permitted if public sewer is [N * r r ° T available'within 200 feet.) Installation will serve: Residence"K Commercial— Other ` M1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: :�DC2e�� w' Water table depth SEPTIC TANK ❑. Type/Mfg ) }�I OC�u�.� S Ca acit ��Z 'Z _ p Y No. Compartments � PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well• - Foundation Property Line LEACHING LINE ❑w No. & Length of lines " 9 7otallength/size FILTER BEU ❑. .Distance to nearest: Well Foundation Property Line s r L 'SEEPAGE PITS ❑.-Depth Size Number h° ,SUMPS I} ❑ 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 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 marer as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the followin ) ce y that in the rformance of the work for which this permit is issued, I shall employ A f p p y persons subject to workman's compensa- tion laws of'Califon ia(" 7> - � The applicant mu c for all requ d inspections. Complete drawing on reverse side. Signed X Title: if Date: y' r FOR DEPARTMENT USE ONLY 3i. . Application Accepted by til Date r IZ a Areaef 1 Pit or Grout inspection by',, i' Date _ Final Inspection bjy Date J Additional CnmmentS:7 f� V "(�.v+n Gam$ /d O 25 ❑ Stk 466-6781' L1 Lodi 369-3621.1.' ❑ Manteca 823-7104 ❑ Tracy 835-63 Pl d t N IM-W Ale Applicant- Return all copies to/:: Environmental Health Permit/Services 1601.E. Ha elton Ave., P.O. Box 2009, Stk., CA 952QKWh�,/'rt>7 LV--k""; Lvw !/FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE r PERMIT NO. + EH 3-24(REV.I 5 �/ D �EH 1 j 1}