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APPLICATION FOR PERMIT ` .i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON--AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED g (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 i Local Health District. s Job Address 2. Y 2©Q L Al � � I°�- City ` Lot Size,I&4GPte PM II� - - I Owner's Name [� Address kin n V �whone Q` f �_R I 4 Contractor �[ Y� Address �^ License Nv Phone��"�7 I TYPE-OF-WEt-LIPUMP: -NE+M-WE-L-L—PI4 --WEL-I-REPLACEMENT--@—DES7fiUCTION-EI ! i PUMP INSTALLATION �]( SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _/M SEWER LINES DISPOSAL FLD./,S70 PROP. LINE � d I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS /�> 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ` Domestic/Private ❑.Gravel Pack ❑ Tracy Type of Casing �� Specifications i7 , i„ (1 Public (1 Other nDelta Depth o#Grout Seal Typ f Grautull Q, I I Irrigation Approxi Depth I I Eastern Surface Seal Installed by tin e4 Repair Work Done ❑ Type of Pump .H"P. Stata'Work-D � ' one Well,Destruction ❑ Well Diameter 7 Sealing Material Itop 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is 4 available within 200 feet.I _ ��_ � ln�talfation-wiil'serve: �R'esii9ence� Com�mercial�_ Other. -�� '�-- ;- �' '>�'�a=-� -" w+=•. Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ' 4 Water table depth SEPTIC TANK ❑ Type/Mfg ? Capacity '�. No. Compartments PKG. TREATMENT PLT. ❑ i � ' Method of Disposal Distance to nearest: Well Foundation Property Line,-• , p LEACHING LINE ❑ No. & Length of lines Total length/size 1, �IIIf +r FILTER BED~ ❑ Distance to nearest: Well y Foundation Propert`y,Line r " SEEPAGE PITS l I Depth Size Number ' SUMPS Cl Distance to nearest: Well ,Foundation 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 Diltrict. ��" FI 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 ;l certifies the following: "[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 myq call for all required inspections plate drawing on reverse side.Wcom r Signed A gJTitle: R DEPARTMENT USE ONLY t , j Application Accepted by t% ;4 wP....C�,...�_ Date ` " t Area �( Pit or rot Inspection bq� ate Final Inspection by Date it Additional-Commer'ts:-�---- - ^�-`-,^- - ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 e; Applicant - Return all copies to: Environmental-Health Permit/Services=-1601-E:MHazelton-Ave.;-P:O:-Box 2009,,-.Stk., CA-952.01--- . I FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO. l l4 INFO CASH f/ IrH14-Zg(REV.t/H5) 0s EH 13-24 Ef G