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�^1-11 'I - APPLICATION FOR PERMIT j,, t" SAN JOAQUIN LOCAL HEALTH DISTRICT /`� �� 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR,FROM DATE ISSUED,. ` u J0 � ... z ?!-,.,(Complete in Triplicate) -41 Application is hereby made to the San Joaquin Local Health District foraermit to construct and/or install the work herein . describedThi li 1 p � application is made in compliance with San Joaquin Count r Ordinance No. 549 for sewage or No. 1862 for well/ pump and the Rules and Regulations of the San Joaquin Local Health District.. *y, T N P f. ,.. i Job Address Y.r t , City4kipovy Lot Size Z t,? ezespm RRA Owner's NameR�.� L /V/1N 7 I c �/ Address/lT�lIA9" — f�R _f�T1j .$r�c�{%(' ne _ Contractor's Name / V + 5 License No -9 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM R -9 -PAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL: OTHER'WELL PITS/SUMP INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS R ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Ex ❑ Domestic/ Private ❑ Gravel Pack ❑ TracyI Type of C VPublic ❑ Other ❑ deka Depth of Grout ❑ Irrigation ---- Approx. 4Depth ❑ Eastern Surface SeaNln Repair Work Done ❑ Type of PumpJ�" ..0 AM yk H. P. _ if d Well Destruction ❑ Well Diameter Sealing Material (top Depth I Filler Material {Below 50'l by State Work Done Dia. of Well Casing Specifications Type of Grout TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Ldp DESTRUCTION ❑ (No septic system permit 'f available within 200 feet.; Installation will serve: Residence Commercial _ Other ,f � Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I F Water table depth_ SEPTIC TANK ❑ Type/Mfg' 1 Capacity No. Compartments PKG: TREATMENT PLT. ❑ t a I I � Method of Disposal Distance to nearest: Well / { Foundation Property Line LEACHING LINE ❑ No. & Length of lines kr ,f Total length/size FILTER BED ❑ Distance to nearest: Will/ Foundation Property Line f SEEPAGE PITS SUMPS DISPOSAL PONDS ❑ Depth _ II .Size ❑ Distance to nearest: /.Well Cl t. 'Foundation Number Property Line sewer is I -hereby ce ify`thafI-ha've-pi'bo# ad`this-application-and that the work' :will bei done in accordance-with=San Joaquiri"county-ordinances,,state-laws; ander= _ rules and regulations of_the San Joaquin-;Loce! Health District. Home owner or licensed agen't's signatuye 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 sucWmanner 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.perfoirhance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California.r The applican.LTuat,call four, a required, nspections. Complete drawing on reverse side. Signed A nF� 4 Title: T _ Date: fa-� C.--. C? FOR DEPARTMENT USE ONLY 7 Application Accepted by Date !� Area 474 Pit or Grout Inspection by" Date Firial Inspection b Date Additional Comments: r ! ❑ Stk 468-6781 / ❑ Lodi 369-3621 Applicant.- Return all copies to: Environm + EH 13-24 MEV. 10183 EH 14-26 Manteca 823-7104 ❑ Tracy 835-6385 th Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. 1 i 4