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APPLICATION FOR PERMIT p pY E dD SAN JOAQUIN LOCAL HEALTH DISTRICT 'REG 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' NMN AL HEAL!" (Complete'in Triplicate) `. Syy1p0 My��SRVICES b, u 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 Ryles and Regulations of the San Joaquin I Local Health District. u4'°' 'wf v' '} Job Address City Size y if rt PM !U i 1 f��)Al r r C,t?I ddress=� S A �7l/ Phone �r - Owner's Name , Contractor e ,clli��fv+�.r� lEJ AddressZOOS 1'O License No. ;Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION X SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST.:, SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP) LINE : 'FOUNDATION AGRICULTURE WELL OTHER WELL PITS/!SUMPS T INTENDED USE. TYPE OFJ6ELL PROBLEMAREACONSTRUCTION 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 Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Su ace Seal Installed by } Repair Work Done W Type of Pump b H.P. J• 4 State}Work-Don I •Csf1{ } r Well Destruction ❑ Well Diameter Sealing Material (top- Depth Filler Material (Below 501 k TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is U? I available within 200 feet.)4 Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPT;IC%TANK %r n ❑ Type/Mfg Capacity No. Compartments a 4t) 4i - PKG. TREATMENT PL-T ❑ f Method of Disposal Distance to nearest: Well ,Foundation- .- — Property-Line-- LEACHING ^ LEACHING LINE ❑ 'No.,&,Le gth of lines— Total length/size FILTER BED ❑ Distance to nearestWell "-Foundation Property Line SEEPAGE PITS ❑ Depth ' Number 1 SUMPS ❑ Distance to neared:,_.--Well Foundation Property Line DISPOSAL PONDS C3 i i 4 I hereby certify that I have prepared this application and that the work will be done in accordance with 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 follo+nrirsg','1 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 ofiCalifornia.r,,'Contractor's hiding 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 workman's compensa- },,.`tion laws.of California ','. The applican st c II-for all re i ctions. Complete drawing on r rse side. ' Signed X f Title: y c Date: FOR DEPARTMENT USE ONLY + �� Application Accepted �by Date �� 2Area Q- } Pit or Grout lnspecti n E: Date Final lnspection by Date"2�� Additional Comments: ! 5 x ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant- Return 611 copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT`NO. 2 + EH iREV.S/SSI M26 EH t428 �� - Z /