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I 9. APPLICATION FOR PERMIT F SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to th(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 welUpump and the Rules and Regulations of the San Joaquin i Local Health District. l Job Address 4 /S Ct CaR� QdCity o Size PM Owner's Name A-Caw-0 lo' Address 1' Lt Rd Jfar^Ao Phone Contractor --�f S�!'�� Address 4 8 License o.�g Phone TYPE OF WELL/PU P: VEW WELL ❑ VALL REPLACEMENT ❑ DESTRUCTION ❑ AL �. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Ir 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 O ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing AOq Specifications ❑ Public n Other ❑ Delta Depth of Grout Seal O Type of Grout I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 _ _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION 1_1 DESTRUCTION I I (No septic system permitted if public sewer is 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 depthR SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal c Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size t FILTER BED ❑ Distance to nearest: ' Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, ar, - rules and regulations of the San Joaquin Local Health District. L` r 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 applicant mu call f all requir d inspections. Complete drawing on rev.rs-e side. �} Signed X Title: �/ -fid(1-��+ Date: I FOR DEPARTMENT USE ONLY Application Accepted byDate Area Pit or Grout Inspection by Dat6y' Final Inspection by Date J Additional Comments: r` `t Tl I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 n Tra 835-638 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE �j�] PERMIT NO. 1 r EH 13-20[flEv.1/H s) [� ^'S1 i"1. A)'.I 2_it / 7�- JW0 OD EH 1a-?A CC�� JJ CJ V o/��J( I }