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j' APPLICATION FOR PERMIT _ w SAN JOAQUINLOCAL'HEALTH DISTRICT I` . 1601 E. HAZELTON AVE. STOCKTON CA Telephone (209) 466-6781 i I PERMIT,EXPIRES IrYEAR`FROM DATE ISSUED y (Complete in Triplicate/ - r Application is hereby made to the$an Jisequin Local Health District for a permit to construct and/or install the work herein described. This-application is made in compliance with San J'oaquin-County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. ; I Job Address L-01—, �t..:` '�` City 7/ H 'Lot Size 7 �z PM ' k - Owner's Name T"' A Ii L.Pk� dress I V-1!/tMA-(V 1 T °! C��` Phone Y34 Contractor rz �z:>✓LT.�L- Address License No. Phone OI TYPE OF WELL/PUMP: NEW WELL ❑ " WELL REPLACEMENT d DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM„REPAIR ❑ OTHER ❑ . DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES --Y DISPOSAL-FLDPROP. LINEr r- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENbE6�'USE TYPE,OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Indusiral"","j. +: ❑ Operl Bottom° ❑ Manteca Dia:'of Well�Excavation Dia. of Well Casing ❑ Domestic iPrivate ❑ Gravel Pack ❑ Tracy ” Type of Casing Specifications ❑ Public' ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ' 'max.'y r ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done El Type of Pump H.P. State Work Done , Well,Destruction f CJ ' f Veh'Diameter Sealing Material (top 50') )Dejth Filler Material (Below 561 4 TYPE Or SEPTIC'WORKr NEW INSTALLATION 11I RE-RAIR%ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is �} available within 200 feet./ - ti Installation will serve: J esidence X_ Commercial_ Other (• Number of living units __. .:_ Number of bedrooms i Character of soil to a depth of 3.feet: t[ , T' � ~�• Water table depth r�, K �, ,...`� I .SEPTIC TAN , O�`I�Type/Mfg Pd ,; Capacity A•.No. Compartments, n ( r PKC.'TREATMENT Pl T. ❑ "Method of Disposal ((}} j s Distancetltto nearest: Well Foundation Property.Line LEACHING LINE No. &-Leingth-of-tines �r3-��Total length/size � �� '---,,FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth /D T Size_ X Y l O Number 1 g .: ,. SUMPS 1 Distance to nearest: Well Foundation property•Line DISPOSAL PONDS ❑ hereby certify that I have prepared,this.,application and that the work will`be'done in accordance with Sari Joaquin county ordinances, state laws, and 1 rules and regulations of the San Joaquin Local Health Disirict.• 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, !shall not 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 workmari's compensa- tion laws of California.", - The applicant must call for ll required.inspections Complete drawing on reverse side ;. Signed "�« ' Title: Date: Yy w i FOR-DEPARTIMENT USE ONLY j 'f. Application Accepted by Date, Area ., � ^ ,. . Pit or Grout Inspection by- � _ Date Final Inspection by Date._.!!� Additional Comments LIStk' 466-M-1 F ❑ Lodi' 369-3621 p Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copses to,rEnvironmental.Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.`CA 95201 r gj - 5-P �►r r FEE AMOUNT DUE'_„: r AMOUNT REMITTED CK RECEIVED BY., DATE t. PERMIT,,.NO. y f, INFO• - CASH - EH 13-24,iAEV-1/$5) �.r - I y EH 14-26 `moo -°�{ -S:dX,. _'4 -