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� I' 'j% II APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r _� 1601 E. HAZELTON AVE., STOCKTON, CA If Telephone 1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; 1Corrlplete 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 fot sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin s Local HealthDistrict. Job AddrewV: _ A IG a r�. City ��+ Lot Size PM - - Owner's am Address N *– '1 Phone �_ i/'�f�.� Contr cto i 0i Runc cry L',l– Al nse No—_-7 Phone 5 r•3 TYPE OF WELL/PUMP: iN NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION.❑ I PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER:❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 3PROP. 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 omestic/Private ❑ Gravel Pack El Tracy Type of CasingSpecifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Tape of Grout t ❑ Irrigation ---Approx. Dept El Eastern Surface Seal Installed by 1 t I `�� Repair Work Done El Type of Pump � H.P. State Work Done S' Clear } Well Destruction ❑ Well Diameter Sealing Material itop 50'1 j } Depth Filler_Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system,permitted if public sewer is , `'"s 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 �? ASEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I PKG!TREATMENT PLT. ❑ if Method of Disposal >j i Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line V) SEEPAGE'PITS ❑ Depth f V ��i Size a Number SUMPS ❑ Distance to nearest: Well Foundation Property Line J DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in adcordance with San Joaquin county ordinances, state laws, and '—rules Gild'regulations'of-the San'Joaquin'Local Health,District:w-....._...,�.-"""�""""— „ 1 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 yfolloing: ',I certifythat in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion lawrnia." iThea t call for II required i l pp q pe ions. omplete drawing jt li O EPARoMENrsTe Uside. Signed Title: Drate:/ ONLY , ©� . Appl cation Accepted by _y��Gt.v. Date `� Area i g r Pit or Grout Inspection by Date Final Inspection by DateZJ I Additional Comments: Ij ❑ SW 466-6781 ❑ Lodi I,369-3621 ❑ Manteca 82:3-7104 ❑ Tracy 8354335 Applicant- Return all copies to:'Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 T E 'I (NFD AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT N0. aa (} +f EH 1324IflEV.z/85l EH 1 �7 426, C�-� r / jO f