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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT E,5 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466.6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED b :, (Complete in Triplicate) rr: rte Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein-d scr'ab" r" made 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. ,�'� - , - ed. This application is Job Address TA 4 To Q City Lot Size PM l .,Owner's Name Pu( M m Address E ��g 3�Y 93Q '".Phone –p Contractor I{{ "p R e T"� { Sba��jddress_.3��t� 1�,t.x3;I SOIJt�� rd 6 � � TYPE U!'WELL/PUMP: icense lVo, 5 j_Phone NEW, WELL REPLACEMENT E DESTRUCTION ❑ Y 4 PUMP INSTALLATION Li SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK 'OTHER ❑ 1 SEWER LINES DISPOSAL FLD, % PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL T INTENDED USE PITS/SUMPS TYPE OF WELL- x PROBLEMAREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial ❑ Open Bottom .0-Manteca Dia. of Well Excavation l ❑ Domestic/Private ❑ Grave! Pack r Dia. of Well Casing ❑ Public ❑ Other ❑ Tracy Type of Casing � Specifications ✓-1 Delta Depth of Grout Seal ❑ Irrigation i 'a Type of Grout —�lpprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of-Pump- `J - r lH.P. State Work Done f Well Destruction ElSeali Well Diameter"`"^ i n - Sealing Material [tap 50') v Depth Fiber Material iBelow 5011 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ {REPAIR/ADDITION ❑ DESTRUCTIO _ {No septic system.. P Y permitted if public sewer is es #dence t Other ; vailable within 200 feet.) Installation will serve: RCommercial Number of living units: Number of bedrooms ; Character of soil to a depth of�3 feet SEPTIC TANKType/MfWater table depth g I �' ��` a: PKG. TREATMENT PLTCapacity No. Compartments .-❑ ""� - •"� =�+":1 , 1 Method of Disposal Distance to nearest: Well r`r Foundation Property Line LEACHING LINE - 3 '�^ .. ❑.; No.'& Length oi�-firres•�-�'–�------.- � Total length/size FILTER BED ❑ Distance to nearest: Well Foundation * I Property Line •��»-�,��II SEEPAGE PITS ❑ Depth ,/ i Size R, �tx . SUMPS .-3 _ Number ❑ Distance to nearest: Well Fountlstron DISPOSAL PONDS ❑l , ,:Y' ; Property Line Y I hereby certify that 1 have prepared this application and that the work will be done in accordance.lnrth San"Joaquin county ordinances, state laws, and rules and regulations of theFSan Joaquin Local Health District. Home owner or'ficense-d agent's stg'nafure ceFtifies the followili an l 9 "I certify tpha�t m th rmancof– employ he work fo Wiich this permit is issued, I shall not' Y person in such marinef'as to become subject to workman's com 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 tion laws of California." / P Y persons subject to workman's com enu a ¢: "_• : .,J / �J i f/� :fir p p 1P' The applicant m c for all required inspection Cam fete drawing on reverseiside. h Signed - -Title: Date: r FOR DEPARTMENT USE ONLY ' Application Accepted by f Date y Area Pit or Grout Inspection by Da Final Inspection by (� Date Y `7- p Additional Gomments: �_.,. –44,– ❑ Stk 466-67$7 L1 Lodi 369-3621 —Manteca 104 ❑ Tracy 835-6385 Applicant- Return l co les to: gnvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009 StkU, CA 95201 4 FEE AMOUNT DUE AMOUN REMITTED # �� ' (NFO CASH RECE D BY DATE ° PERMIT'Np, +EH 13-24(REV.t/85) J EH 1426 t t�N1�t `Jr► U 'l d � �� i �: