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AAPPLICATION FOR PERMIT 10 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I'VEAR FROM DATE ISSUED (Complete in Triplicate) 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 Rules and Regulations of the San Joaquin Local Health District. ' A Job Address /�[/ pev �X/ City Lot Size PM Owner's Name 1 iN�+r // �FTZk./Yt.-� Address Phone Contractor Address License No. Phone TYPE OF WE NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ '-SYSTEM REPAIR ❑ OTHERX '' S DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION ! AGRICULTURE WELL OTHER WELL PITS/SUMPS _ - /, ' n INTENDED USE —4 TYPE OF WELL )&ROBLEM AREA`)tUNSTRUCTION SPECIFICATIONS �c � 9,,I'=d! Industrial Open Bottom - ;❑ Manteca Dig. of Well Excavation . _. .. Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F) Public ❑ Other 11 Delta Depth of Grout Seal ' Type of Grout_ I I Irrigation _.Approx. Depth I1 Eastern --- .Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501) TYPE OF.SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/AODITION I I ,DESTRUCTION I I (No septic system permitted if public sewer is WOLF -- -" - . available within 200 feet.) 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 SEPTIC TANK ❑ Type/Mfg. _ Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest! Wall - - Foundation : Property Lino LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ :Distance to neaMIR: ---,Well Foundations Property Line SEEPAGE PITS I I Depth _ Size - Number SUMPS ❑ Distance to nearest; Well Foundations Property Line 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 D3trict. 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 aubjeot to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the peMorntance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws o iteF ' f The appli cal r all required Inspections. Complete drawing on reverse side. i...._�. Sign i Title: Date: /0990 F SPAR USE ONLY q App(cation cc pled by _Yom' C�� Date �' —` it Area Pit or Grout Inspection by z� ' Date_ F' al Inspection by Date Additional Comments: _ �91��K ElStk 466-6781 13Lodi 369-3821 O Menleecfe 823-7104 " ❑ Tracy 835-6385 s Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNt REMITTED C K RECEIVED 11y DATE nPERM17NO,LINFO '��EEl� E r^I,EN❑N(REV.1/951 3S'"" 3S'vv i. (� /H Nle �— I—�O 7