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APPLICATION FOR PERMIT SAN JOAQUINTLOCAL HEALTH DISTRICTj`I .a 1601 E. HAZELI ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FEB .w�+ 4 - (Complete in Triplicate) CNV1R0, �r �c M �TAL H�A {� Application is heteby made to the San Joaquin Local Health District for a permit to construct and/or install theEwgi4tf4H� �rtdescr gd.�THis'SppGcation is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regula i s-of the San Joaquin Local Health District. Job Address ZZ� �._ City Lot Size ® PM Owner's Name _in r, I Jt3V L4 "1 S � ,]Q Phone ddress Confracior Address 71457 - k`1ieI� Icense No. 3 f Z Phone337'4 30 TYPE.OF:WELL/PUMP:' - NEW WELL. ❑a WELL•REPLACEMEN DESTRUCTION O r t PUMP INSTALLATION ❑ SYSTEM PAIR El OTHER ❑ y. f DISTANCE TO NEAREST: SEPTIC TANK, SEWERfLINES� DISPOSAL FLO.� PROP. LINE ,{ \ ^ .:sea-.�f�=�• -.r'a� -'.ia3.. . _ - .FOC1N�]ATION'�- r �.,4GRfCl1LTURE�lUEL"L OTHER`1111ELE PITS/SUMPS .INTENDED USE .;,TYPE:,OF.WELL t- PROBLEM AREA CONSTRUCTION SPECIFICATI NS } 4P ❑ IndustrialOpen Botta- ❑ Manteca g;{ Dia. of Well Excavations PV- -n Dia. of Well Casinga�IZ ❑ Domestic/Private ❑ Gravel Palo:_ L1 Tracy µ`Type of Casing_ Specifications �o r 4 M Public F1 Other F11 Delta Depth of Grout Seal Type of Grout �+[Irriyation � �-Ap�7t'px�DB`pth l'-I"E"as#eFn"'"'"""""'"'—Su"rfac-e Seal"Installed"bye--'-^�-�^�*-�-•^^w--'-'^•-Y-~^-''^+' Repair Work Done ❑ Type of Pump H,P. State Work Doric Well Destruction C7. Well Diamete Sealing Material (t '1 Depth Filler Materi Blow 50'1 e _._..-_ TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I 1 DESTRUCTION 111No septic system permitted if public sewer is ( available within 200 feet.) Installation will server Residence Commercial_ Other £ Number of living units: Number of bedrooms14r Character of soil to a depth of 3 feet: ,,�4 1 Water table depth i j' SEPTIC TANK a ❑ Type/Mfg Capacity No. Compartments 44 PKG. TREATMENT PLT. ❑ XMethod of Disposal, ` -' �c Distance to nearest: We Foundations Property Line LEACHING LINE ❑ No. & Len th of lin f '� f g Total-length/size FILTER BED ❑ Distance to ne st: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number 1 ,SUMPS: ;;.L-�—Dist ce.to-nearest: �Well .> � Foundation--::—� ;Property Cine: •=-. - _ 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. y 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: "Icertify 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 applicant mustpail for all required ins ctiaits. Complete drawing on reverse side. 4 1. Signed X Title: Date: 0 FOR:DEPARTMENT-USE-0NLY—. -__"_.,.._-,-_ ( — Application Accepted by. Date �-.�7--� :.Area ! i? Pit or Grout Inspection by bate Final Inspection by Data Additional Comments: *,•, ❑ Stk. A66-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 A_ppli �II c pies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2!X19, Stk., CA 95201 f > �- [ • Retu r FEE AMOUNT DUE AMOUNTREMITTED CK 4 RECEIVED BYPERMIT'NO. INFO CASH kD TE EH 13-24(REV.1/"51 r...r t EH 11-211 .. _