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APPLICATION FOR PERMIT SAN JOAQUIN'LOCA L HEALTH DISTRICT 1601 ,E. HAZEL T ON AVE.,,STOCKT_ON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED n..r N .(Complete in Triplicate} > u.��' F =��.. 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 made in compliance with San Joaquin County Ordinance No.54.9 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 1 � yr � ?�3 I Job Address _ .City.. Lot Size 4 PM Owner's'Name S-= ress �� Phone Contractor v Address License_No. Phone_ TYPE OF WELL/PUMP-- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION E1 a,-,SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA ' CONSTRUCTION SPECIFICATIONS ❑ Industrial I ❑ Open Bottom ❑ Manteca t. 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 of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seat Installed by Repair Work Done ti❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ . DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other i Number of living units: Number of bedrooms x / Character of soil to a depth of 3 feet: Water table deptti ` SEPTIC TANK ❑ Type/Mfg Capacity F No. Compartments -1-Zy PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well- .Foundation Property Line LEACHING LINE f ❑. No. & Length of lines- .,.__l` € + k g Total length/size $ '\ FILTER BED ❑ Distance to nearest:o i Well + - Foundation ; 4 Property Line SEEPAGE PITS L ❑ Depth `Size Number SUMPS I ❑ Distance to nearest: Well ' Foundation E Property Line w DISPOSAL PONDS- ❑ hereby certify that 1 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 licensedagent'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 wiorkman's compensation laws of California."Contractors hiring or subcontracting signature certifies the following:'9 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." V 1 The applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: Date./ Z �0 i OR DEPARTMENT USE ONLY Application Accepted by Date -�3`"h Area -- . Pit or Grout Inspection by rt Date Fin Inspection b Date 6 XSt Tonal Comments: Ok 466 6781 . ❑ Lodi 369-3621 ElManteca 823-7104 1-1Tracy 835-6385 cant- Return all copies to: Environmental Health Permit Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4 IFE6 AMOUNT DUE AMOUNT REMITTED # RECEIVED BY' DATE PERMIT'MO. +-EH1 3-24 4REV.€1tis --a^�"^�' /p/ WET �-T� ('� f •yam EH 14.28; a�V T 1 U _. ✓ L x~s-.7` p,� Z7