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Alt- APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA II Telephone (209)'466-6781 d5 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. 3 i - y.. (Complete in Triplicate) ��;, 3 -7 c a 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 H 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 S • r ,., Cr Lot Size PM i1 Owner's Name • Address �� /"`�- wp _ Phone s G� fY 55 38 l�o-rt.> f Gc.c x Contractor $ C� j//—? �f f TYPE OF WELL/PUMP: License No. !/ Phvne b' - NEW WE ❑ W CEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ M DISTANCE TO.NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION. AGRICULTURE WELL — WELL i PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS # ❑ Industrial ❑ Open Bottom y❑ Manteca Dia. of Well Excavation r Dia. of Well Casing O Domestic/Private ❑ Gravel Pack ❑ Trac + Y Type of Casing Specifications + ❑ Public O Other ❑ Delta Depth of Grout Seal Q Irrigation Type of Grout ---,Approx. Depth E.3Eastern Repair Work Done ❑ T I "" ' .,�mSurfiace,Seah Installed.by .�. ypump; LJ Destruction Welll of P Diameter J H.P. State Work Done Sealing Material (top 50'I ' i Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION 1 . (No septic system permitted if public sewer is �� vailable Installation will serve: Residence Commercial` Other within 200 feet.) Number of living units: Number o�bedrooms ACV, j 41,nJ Character of soil to a depth of 3 feet: SEPTIC TANK Water table depth ❑ Type/Mfg '. Capacity PKG. TREATMENT ALT. ❑ No. Compartments f - Method of Disposal •s f Distance to nearest: Well Foundation Property Line f LEACHING LINE ❑ Na. & Length of lines It ' FILTERED Total length/size ❑ Distance to.6earest: Well Foundation I Property Line SEEPAGE PiTS D Depth Size ! SUMPS Number ❑,. Distance to nearest: Well Foundation I---- DiSPOSAL PONDS ❑' t Property i Thereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county/br&An e%g, 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 prmR is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or'sdtfcontracting signature \' certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall em to g tion laws of California." I t employ persons subject to workman's compensa- The applic muse call for all requi ed inspecitions. Co plet Ing on reverse side. �� # rx s ; ori Signed �x r `✓i itle: -:k . R Date: ! FOR D RTMENT USE ONLY q�` ! Application Accepted by Data � +�, �"�a/,.•.}Area Pit or Grout Inspection by Date ' Final Inspection by pate gitional Comments: � V'15/ L• )' tk 466-6781 ❑ Lodi 369- 1 ❑ Mante 823-7104 ❑ Tracy 83 6385 ` } Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,.P.O. Box 2009, Stk., CA 95201 f z�' } FEE INFO AMOUNT DUE # AMOUNT REMITTED CK ` `RECEIVED BYf DATE PERMIT'NO. I� f� + EH'13.24IREV.14851 ---��-- 1 r � f t EH 1429 : `� /� !R�b a4l .ri4 x - « 4. .. - ... Z�.n!✓Gn ca,.r M,�.r.. .. ,. !l 4�'S� 3^JreU•/