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- SSA APPLICATION FOR PERMITN�� %�, � P SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE T ON AVE., STOCKTON, CA 4W,41V�2�q4 Telephone (209)'466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 'yF�+ zr (Complete in Triplicate) Application is hereby made to the San Jo�quin 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 Rules and Regulations of the San Joaquin Local Health District. f Job Address City "Aa tot Size PM Owner's Name Address Phone�t.11. 1 {sPf Vi tt. 5 a1 up 0 Contractor `ie .. Address License No.' Pho e i NEW WELL WELL REPLACEMENT LJ- DESTRUCTION ❑ TYPE OF WELL/ UMP: y PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �J/f'yh✓ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OT WELL PROBLEM AREA -CONSTRUCTION SPECIFICATIONS`� `'- '� 41 or ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications E fl Public hov\,}Df— ❑ Other 171 Delta Depth of Grout Seal tiZj{ Type of Grout dei S. I I Irrigation App(ox. Depth I 1 Eastern Surface Seal installed by - r _ Repair Work Done ❑ Type of Pump H. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') t Depth I Filler Material IBelow 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATlON I] REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public sewer is r available within 200 feet.) { Installation will serve: Residence i tt Commercial_ Other Number of living units: Number of bedrooms PA Character of soil to a depth of 3 feet-1 Water ta� SEPTIC TANK ❑ Type/Mfg Capacity No. Compartmen s } VIED PKG. TREATMENT PLT. ❑ E1 MethocGIi p f1 Distance to neatest: Well Foundation Property Line �1 1989 LEACHING LINE ❑ No. & Length of lines Total length/size NMIN FILTER BED ❑ Distance'to nearest: Well Foundation Property Line 'S I J !t v I SEEPAGE PITS I i Depth I Size Number r SUMPS Ll Distance to nearest: Well Foundation Property Line _DISPOSAL'PONDS El - + µ - , r - l hereby certify that I 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 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."Contractors 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." I The applicant ust call for all required inspections. Complete drawing on reverse side.�� "ICG 4�1L'1D tJl"Lt �Sy �^ e Signed X Title: 0 1 Data: f FOD TMENT USE ONLY Application Accepted by �{ Date Are Pit or Grout Inspection by i Date Final Inspection by Date Additional Comments: i C Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, S1k., CA 95201 t� FEE AMOUNT DUE: AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO / y�y +-£H t&24(REV.tiy51 _ JS C9 0 - EH 14-2a