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APPLICATION FOR PERMIT .. ., IV . SAN JOAQUiN LOCAL'HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 7elepFlone (26) 466-6784 PERMIT EXPIRES-'T YEAR FROM,DATE ISSUED ` w. (Complete ln•Tflpllcate) . .f,. fir.. -..t�-'c-`1., '.'.. -..-�}t]7t.}�.':lL�'>:!1 '�lt.';��v3•'a) '.. .,E .-t. -.,_j.... � - Application is hereby made to the San Joaquin Local Health District for a permit to const16F.ruct and/or install the work herein described. This application is made H compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and,the Ryles and Regujvn�"h San Joaquin Local Health District: s s yfis rv./ ir S- -.' .v 4 F 1 T /.1 Job Address ' a t0:� '*s1f fk City t 5 'iLJ 4 Lot Size L97 1t{ � s;}€ iE} l{: � r } r N PM --Owner's Name �E�.r�..a�t c. Q, /�'JO Address - 7 . _ Phone = r Contractor -License No. Y 73-- Phone .T3 97 F iT.,YpE O�G47ELL/.PUMP_;.,{ NEW WELL ❑ 'WELL REPLACEMENT ❑ J DESTRUCTION ❑ g�w rij�r PUMP INSTALLATION ❑ ? SYSTEM REPAIRp DISTANCE TO NEAREST:�SEPTIG TANK j OTHER ❑ SEWER L1NE5 DISPOSAL FLD.' PROP. LINE + "°t k." . FOUNDATION* 4- AGRICULTURE WELL OTHER WELL/' PITS/SUMPS `*' € INTENDED USE �' 7Y,PE OF WELL.{ "rPROBLEIbtAREA CONSTRUCTION SPECIFICATIONS � ❑ Industria! ► ❑ Open Bottom ' i ❑ Manteca xcavation Dia. of Well EDia. of Well Casing j❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T ' +, ype of Casing f L7-Aublic- =a ❑ Other Z Specifications -"'� ❑ Delta -,Depth of Grout Seal ' ❑ Irrigation —Approx"Deptr❑ EasteFr { Sup6e- I stalled by Type of Grout S� e Sea In r Repair Work /Sone""-- ❑ Type of PumpH.A_` / ti l State Work Done 1 } Well Destruction3 ❑ Well Diameter ,c Sealing:Materfai [top 50'j� ..�-�'`. ' Depth Filler=iBelow 50'1 ' ~ : TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑^fNo septic system permitted if public sewer is ' I '`fir available within 200 feet.) ;Installation will serve: RI. esidence Commercial ;ether r Number of;living units: _ Number of bedrooms_ Character of soil to a depth of 3 feet: tri. SEPTIC TWater table depth ANK r� Type/Mfg �C —' f qE� i. PKG. TREATMENT PLT. ❑ capNo.No. Compartments' } I �,f�� Method of Diosal Distance to nearest:/Well — Foundation �� property Line.�� 1 � t LEACHING LINE No. & Length-OV FILTER BED / ti Total length/size 1 - ❑ Distance to wrest: WellFoundation �,//� Property Line.��. �. f SUMPS SEEPAGE PITS IF7Dapth / Size --# Number. Distance to nearest: Well �. DISPOSAL PONDS ❑ Foundation _ property Line ` I hereby certify that I have prepared this application avid that the work will be done in accordance with Sari Joaquin'county ordinances, state l f-»icerules-and-regulaticns of-the-San'`Joaquin Local Health District. aws, and Home owner or licensed agent's-signature certifies the foll wing,: "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 rsubject•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 em to t of n=laws of:California.'; fy x employ persons subject to workman's compense- The applicant must call for all required inspec ns. Complete drawing on reverse side. Signed - r t#. Title: Date: FOR DEPAR MENT USE ONLY Application Accepted by v`�- �� Date Area Pit or Grout lnspection by " Date -- r Final Inspection by - Date Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 835-6385 Jf r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.; P.O. Box 2009, Stk., CA 95201 ! ffE MOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE - - PERMIY`NO. - , EH 13-24(REV.t/85) �� O EH 1428 y, . A I _ y� j ""- ., i1iZ / /y-�fp Z f