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�V A - APPLICATION FOR PERMIT =, SAN JOA¢UIN'LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 4 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete 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 Rules and Regulations of the San Joaquin Local Health District. r Job Address city Lot Size 'W fWAU PM Owner's Name Address ��.�e.l33Z7 /�Oc>IGS �,� Phone F Contractor i1ZR{SY► -Address pHAP icense No..2��3__Phone -.� r TYPE OF WELL/PUMP: 1NEW WELL-0---._,v;WELL REPLACEMENT E1,; DESTRUCTION Ll PUMP INSTALLATION ❑ SYSTEM REPAIR= OTHER-9 b STANCE•TO NEAREST: SEPTIC TANK SEWER LINES.- DISPOSAL FLD "PROP-L-INE__ f FOUNDATION- -AGRICOLTURE WELL OTHER WELL____L PITS/SUMPS INTENDED USE tea, TYPE OF WELL PROBLEM AREA—CONSTRUCTION SPECIFICATIONS I -4C O-industrial `�,� ❑tOpeWBb tom El Manteca Dia. of Well Excavation--- Dia:of Well Casing ❑ Domestic/Pnvate ❑ Gravel Pack ❑ Tracy Type of Casing 5pec1ficationsy ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 7-Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done d Type of Pump H,P. State Work Done ( } Well Destruction ❑ Well Diameter Sealing Material {top 501 I Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ■ DESTRUCTION ❑ (No septic system permitted if public sewer is I ! 9 t available within 200 feet.) 0 Installation will serve: Residence— Commercial_ Other XN 94L 7 --y-• 0 Number of living units: — Number of bedrooms { Character of soil to a depth of 3 feet: -Si4+rDY 1-0&17 Water;table depth 0 ? SEPTIC TANK 4 Type/Mfg CONCItt+r-,dr/IPARZIS14 Capacity .34600 No. Compartments p PKG. TREATMENT PLT. L1Method`of Disposal Distance to nearest: Well Zoo Foundation_,(C70_ Property Line"?/f00 LEACHING LINE ❑ No. I!ength of lines Total length/size f FILTER BED ■ Distance to nearest: Well too'� Foundation /cta" Property Line i!oo"` SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Cine " a DISPOSAL PONDS ❑ t r hereby certify that I have prepared this application and that the work will be done in accordance with S_an Joaqu`irrcounty ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I4 . 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 subcontracting 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." e V t x The applicant must call for all required inspections. Complete drawing on reverse side. " c J 1 � r Signed Title: .,,N_LG>2_^� SLA, ! Date_ _IA Cs 4 . r FOR DEPARTMENT USE ONLY Application Accepted by Date} TMJ'l7' / i Area ' Pit or Grout Inspection by Date Final Inspection byt ate,�� , � 1 F Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i. 3( Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.FO.',Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY; _� DATE ,_PERMIT`NO. INFO + EH 1324 IREV.f/e 51 ``'] T^ ��'�{�A�- .; _ gi EH 14-26 ! e Ob