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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,.STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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. t .� p^, 15n:10 Job Address �,Z T//✓/5_i /aL aCZ- City Lot Size- - PM Owner's Name 4 eo Address Phone Contractor 1$ mfg 11LS Address.3!0, 168 T • License No.�,�„s934� !shone 60 TYPE OF WELL/PUMP: i NEW WELL ❑ --- WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKSEWER LIN ES' 1 �r DISPOSAE'FLD. P-ROP. LINE_ ��, , FOUNDATION AGRICULTURE WELL — OTHER WELL PITS/SUMPS r INTENDED USETYPE OF WELL PROBLEM AREA - CONSTRUCTION SPECIFICATIONS s Ih ❑ 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 TySe of Grout ❑ Irrigation 14 --Approx. Depth ❑ Eastern Surface Seal Installed by '- Repair Work Done' ❑ Type of Pump H.P. State Work Done_ ~ ' Well Destruction ❑ Well DiameterSealing Material(toptop 50') l r Depth Filler Material (Below 50') TYPE OF SEPTICMORK: NEW INSTALLATION ❑ REPAIR/ADDITION ! eDESTRUCTION ❑ (No septic system permitted if public sewer is I~ " available within 200 feet.) ! N Installation will serve: Residence Commercial— Other Number of living units:-I _ Number of bedrooms .3__ Y I Character of soil to a depth of 3 feet: WEE t Water table depth ; SEPTIC�TANK � ❑ Type/Mf 9 Capacity No; Compartments PKG. TREATMENT PLT. ❑ I I' Method of Disposal Distance to nearest: Well Foundation Property Line . s LEACHING LINE t ■ No. & Length of lines i� �" _ Total length/size FILTER BED e ❑ Distance to nearest: Well_M/59 Foundation i I LLV" Property Line /D SEEPAGE PITS ' - -- ! Depth _.mss _Size . Number_- - �• Ff `(_ X_ n SUMPS ❑. Distance to nearest: Well ` Foundationr ��Prnper`tys Line LQ'� 1 d DISPOSAL PONDS ❑ ;, N. t 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 JoaquinFLocaLHealth..Dit1+ct..) ' Home owner or licensed agent's signature certifies the following; "I certify that in the performance of the work fZhich this permitFis ssued, I shall not employ any person in such manner as to becomesubjeci to workman's compansatian favus of.Calif:' ia.'„Contractora-hiring or sub-coritractingsignature 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 applicant must call for ail required inspections. CqMpI3te drawing on reverse side.... y ',v , Signed X - t, q' Title: R Date: 04- J 840 t r r.'#OR DEPART ENT USE ONLY Application Accepted by '� `• _ f'� f �, Date - ' Area ` Pit or Grout Inspection by Y' pate �•F ori-b, -- F -M1 Final I spectiomb'Y - Date Additional Comments: } ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104- ❑ Tracy 835-6385 x Applicant - Return all copies to: Environmental Health Permit/Services-1601 E. Hazelton Ave.,,P.O. Box 2009, Stk., CA 95201 I _FEE �. ,- AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO" INFO CASH 118 �f EH13-24'IREW1i7'p'S1 "^'".��_�. y�.•-,-y--•r..+r�•r - EH 1 +G-+^"----J--1-+--+ .r•.�... .S426 l 0 zi 6