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i APPLICATION FOR.PERMIT k o- SAN JOAQUIN LOCALMEALTH DISTRICT k 1601 E. HAZELTON.AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED ' ' (Complate 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 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. <:' '° „ ' - 11°*v w .-k q t Job Address ��y b R�. 9 I `"" 'j� t`• City. : .�t' 'Lot Size pis �F PM Owner's Name .�+�_ _-N)AA kr Address ` 4 S Phone Contractor Address _ u-'t License lVo. Phone TYPE OF WELL/PUMP: NEW'WELL-E1- "'""— WELL REPLACEMENT ❑ DESTRUCTION' ❑ PUMP INSTALLATION C r _ SYSTEM REPAIR_❑ "� OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ~SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i 9ah w - INTENDED USE TYPE OF WELL PROBLEM AREA f CONSTRUCTION SPECIFICATIONS w V v ❑ Industrial ❑ Open Bottom 0 Manteca r` Dia. of Well Excavation Dia. of Well Casing ~r- f �~ ❑ Domestic/Private ❑ Gravel Pack' `---"❑ Tracy' '- Type of Casing Specifications , Q ❑ Public 171 Other 11 Delta Depth of Grout Seal Type of Grout ❑ Irrigation i —Arprox. Depth ❑ Eastern Surface Seal Installed by— Repair y Repair Wolk Done D Type of Pump H.P. State Work Done -�-- Well Destruction J. Ll Well Diameter Sealing Material (top 501 Depth i Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTAL A I`ONErREPAIR/ADDITION DEIT�RUCTION 0 (No septic system permitted if public sewer-is Er 4 available within 200 feet. 4 Installation will serve: Residence Commercial Other' Number of living units:' ' ° Number-of bedrooms Character of soll to a depth of 3 feet: Water table depth SEPTIC TANK d Type/Mfg ' Capacity ' No. Compartments;"'4 OL4' PKG. TREATMENT PLT. Of * Method of Disposal Distance to nearest:-4,r Well__..-fib=.:-._,Foundation f 0 f Property Line �S N s c, -a•a. E LEACHING LINE R1 'No. & Length of dines Total length/size FILTER BED ❑ Distance to nearest: Well a•oat Foundation� Property Line -,. SEEPAGE PITS 0"Depth 1 Size �l � Number i» __7 SUMPS ❑ Distance to,nearest: Well a=-+ Foundation ._.Propertyv'Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with Sandoaquin county ordinances, state laws, and rules and regulations'of the San Joaquin Local Health District. .- Hbme owner or licensed°agent's signature certifies the following: "F certify that in the performance of the work for which this permit is issued;I shall not p 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_Vy;�- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. o d Signed X f Title: r�-�c-C_ ;; _Date://`'2S OR DEPARTMENT USE'ONLY - Ap lication Accepted by Date' - <Aiea 1 '' rf Pit r Grout Inspection 6 � ate 4 I� ' pe y Final inspection b � Date l - Additional Comments: ' 1, ❑ Stk 466-Ml ❑ Lodi 369-3621 ❑ Manteca 82Y-7100 ❑ Tracy 835-6385 .�"- .� " x , Applicant'-Return all copies to: Environmental Health,Perm160 it7Services 1 E. Hazelton Ave., P.O. Box 2009, Stk.',,CA 95201 V FEE AMOUNT DUE: AMOUNT.REMITTED RECEIVED BY- __ DATE _ PERMIT NO. .,. } INFO __ CASH—- �.. 1 + EH 13-24 tREV.,/e 51 EH,azs ©i3Z �. v r