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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT + 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED p `S' el��i �I � �N�+ (Complete in Triplicate) F,^y��yq��✓o 1!f �,6 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work heren 4r UVJ p�fi�!on is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Reg f ��ry1 Joaquin Local Health District F4�r Tr Job Address n �F, City !,� e— h� Lot Size PM I�� Owner's Name Address �3 �G'�°" k ��1 yC � Phone Contractorllf//(1[s aK(J Address r f7/ C�' icenseNo. ,I C-b ) Phone J TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMErIT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK bid SEWER LINES DISPOSAL FLD. A/2 9- PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL _26 PITS/SUMPS �� `INTENDED USE TYPE OF WELL PROBLEM AREA—CONSTRUCTION SPECIFICATIONS ❑ Industrial © Open Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private >1 Gravel Pack k Tracy Type of Casing 40V Ci Specifications f'} Public Cl Other C1 Delta Depth of Grout Seal Type of Grout !!/"NiTCr I I Irrigation Approx. Depth I I Eastern . Surface Seal Installed byLL f /p_ 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 RLPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is 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: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS L� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r I hereby certify that t 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,t shall employ persons subject to workman's compensa- tion laws of California." The applicant m It call for all required ins , ions. Complete drawing on reverse $de. Signed ANN�/�f c�S ��5 Title: Date: —71 FO DEPARTME19 USE ONLY ] `r I �! Y Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date 7 Additional Comments419 ! a W ' k w, ❑ Stk 466-6781 13Lodi�369-3621 ❑ Manteca 4(2j-7id Tracy 635-6385 elcr-H, - r a Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 . IEEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE //�� PERMIT'NO. +.EH 13-24(REV.e i x sl �( �� ,1./' ' EH 14-2e I l GG..77 ll UU