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APPLICATION FOR PERMIT ) I ,� g SAN JOAQUI.N LOCAL HEALTH DISTRICT MAY 2 ' 1601 E. HAZE i ON AVE., STOCKTON, E Telephorle.F(209) 466-6781 � tQ :3, l Pt+Ntt'CE PERMIT EXPIRES 1°YEAR FROM DATE ISSUED rt R ' ! } (Complete in Triplicate) W 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 Not 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. "�� k Job Address City / a C'� Lot Size � ' PM Owner's Name �— , ` �-G- Address 0e�U!'u ZL�rP/' Contfacto 1 " ftl � Address 9� l icense No. hle TYPE OF WELL/PUMP; NEW WELL WELL REPLACEMENT ❑ DESTRUCTION Q � PUMP.INSTALLATION ❑ A,-SYSTEM REPAIR ❑ OTHER,0 - DISTANCEJO.N!_AREST: SEPTICJANK= SEWER LINES --DISPOSAL FLD:�11 ROP. LINE- FOUNDATION, `�-f-. "AGRICULTURE WELL4,2X)'4-- ! OTHER WELL „�"0] PITS/SUMPS -Z)0 t INTENDED USE y TYPE OF WELL PROBLEM AREA 1 CONSTRUCTION SPECIFICATIONS• Industrial ,1/ ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ' ` }� Dia. of Well Casing ❑ Domestic/Private Q-Gravel Pack allfracy Type of Casing e � �p cif*cations (`l Public f l Other . ❑ Delta Depth of Grout Seal f e of (;rout I I Irrigation .�_Approx".'Depth I I Eastern Surface Seal Installed by � �� Repair Work Done ❑ r..Type of Pumy p 7t _ H.P. " /! � — State Work Done Well Destruction ❑ Well Diameter Sealing Material (topA ) Depth (^� Filler Material {Below 501 TYPE OF SEPTIC_ WORK: NEW INSTALLATION I 1 REPAIR/ADDITION'i-I DESTRUCTION I 1 (No septic system permitted if public sewer is t - available within 200 feet.) +- -Installationwill-serve:-.Residence-= Commercial=4 Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑" Method of Disposal Distance to nearest: Well Foundation Property Line � v LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line > - SEEPAGE PITS 1-1 Depth { Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line -.�� _ j DISPOSAL PONDS. ❑ 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 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 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." f } The applicant t call for alluired ins 1`01 s. Complete drawing o rse side. Signed XYl�`t!�" �.tu` ,.t� Title: . } Date: # FOR DEPARTMENT USE ONLY Application Accepted by Date i Area Pit ar Grout IrSspection by e 16 Final Inspection byMzffDate G �� Additional Comments: - �3Yv tt-f- 3 Y i ❑ Stk 466-6781 - ❑ Lodi 369.3621 Mant ca- 823-7704 ❑ Tracy 835-6385 Applicant - Return all Cqpies to: Env* nmental Health Permit/Se rv' es 1601 E. Hazelton Ayp,, P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE ptPEERMIT'NO. +.EH 13-24 IREV.t/x 5) 105 d V 105- !V}(� f!J(�,/. - (�'^rc'�-ela r EH 14-26 `✓ ��I/