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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTO.N AVE.,ISTOCKTON, CA 'Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y ,a . (Complete in Triplicate) J -« 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.5,49 for sewage.or No. 1.862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. T Job Address - � �� 'RD City- � Lot Size Owner's Name VA Thi+ / Address ��Y1�1� _ Phone99', !� Contractor��] LI Address C f _ icen_se'No-. , � Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD- PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ,-^- -•INTENDED-USE TYPE-OP-WELL- PROBLEMA'REA---.CO'NSTRUCT N,SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing - "' Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seals Type of Grout - ❑ Irrigation �-=.Approx. Depth ❑ East_ern —S,urface Seal Installed`by' Repair Work Done EJ Type of Pump H.P. it State Work Done a - ' Well Destruction ❑ Well Diameter Sealing Material ltop 501 Depth " ' ri` 1 Filler Material (Below 501 t TYPE OF SEPTIC WORK: NEW INSTALLATION gL-JWPAI R/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is I 1 available'within 200 feet.) Installation will serve: Residence_ Commercial L'�her 7 Number of living units: Number of b Brooms Character of soil to a depth of 3 feet: E, ' '�� Water table depth SEPTIC TANK 6--"ype/Mfg ��', G 4 Capacity _��, �No. Compartments PKG. TREATMENT PLT. CJ, ? Method of Disposal 1 Distance to nearest: Well Foundation Property Line i LEACHING LINE & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Weil Foundation Property Line E t i SEEPAGE PITS ❑ Depth _ i e ° Numtier _ tr . r SUMPS �istance to nearest Foun ati Property Linek/W � DISPOSAL PONDS s ❑ t r'4f-t 4 1__9 «4}. s p I hereby certify that I have prepared this application and that the work will be-done in accordance witif 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..!Contractor's hiring or sub-contracting signature certif aes the following: "I certify that in the performance of the work for which this permit is issued,I shall employper'sons subject to workman's compensa- tion la f California.'.' ; i The applicant ust call for Il re )red i pact' ns. mplete drawing on verse si e. Signed - Title: i � Date:' t FOR DEPARTMENT USE ONLY r Application Accepted by Data 3 Area ,\,04, Pit or Grout Inspection by r_.Date -Final Inspection by lAilx,IA bte��' Additional Comments: E Stk x486-6781 ElLodi 369-3621 ❑ Manteca 823-7104 ❑ Traci 835-6385 -"=•;4pplicani- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I /tFEE a INFO AMOUNT DUE AMOUNT REMITTED 'I, * RECEIVED BY GATE PERMIT N0. t I+ EH 114-2a I 3-24(REV.i/N 51 H - , f /� .,O b S r t F- - „.E . r �� f F