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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZELTON AVE., STOCKTON, CA Telephone Q09) 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 incompliance with San Joaquin County Ordinance No.549 for sewage or No. 1851 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. + Job Address �� City Lot Size ! Owner's Name + ie`sAddreAT-4779i�e� Phone k Contractor Address �� /S�'r` ense No.A 74 Tq -Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ . PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ „ DISTAN CE-T.A-N EARESf"SEP`F1C--TANK--.-. — -- SEWMLINES�_ n1SP.OSAL-ELD.- P-ROP. LINE FOUNDATfON AGRICI7CTFIRE,WELL � OTHER WELL PITS/SUMPS E INTENDED USE TYPE OF WELL E PROBLEM AREA' 'CONSTRUCTION SPECIFICATIONS Y." 'CTlndu`st7ial pen.Bottom .-r:— MantecaDia of Well —- __,_Dia..of Well Casing ❑.Domestic/PrLte -bGravel'P Ilk. ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout t I ❑ Irrigation y pprax. Depth C]�astern Surfata Seal Installed by ' Repair Work D ne ❑ ' Type of Purnp I- �' ! H.P.It - St4te,Work Done r Well Destruction ❑ Well Diameter Sealii'< Mad erial stop 50'1 I � Depth Filler �atenal (Below 50') � t 04 1 TYPE OF SEP IC WORK, NEW INSTALLdTIQ ip REPAIR/ADD/ON DESTRUCTI W� (No septic system permitted if public sewer is I( � V available within 200 feet.) Installation ill serve: L nce_ Comritercial Otht'isr ' ; Number of lid Ing units: Number of b rooms///!!! d Character of soil to aidhpth of 3 feet: r i Water table depth SEPTIC TANK+ _ ❑ Type/Mfg Capacity to. Compartments PKG. TREATMENT PLT. ❑ g l �ethod of Disposal Distance to nearest: J j,Well ''::= Foundati r pe+rty }me ` LEACHING LINE ' l�lo &L ngt!of lines "°" " ,.'7��ottaal len th/size FILTER BED K fStan1 to nearest: Well�v `-F`ou td tivrt ,� Pra ert�y 'ineL J - _�� -- ..rte -- -. � SEEPAGE PIT ?�YUepth Size Number _f �� SUMPS i ❑ Distance to nearest: Well FoundationPor party Line �r DISPOSAL PO#DS Cl k J ZtZ M I hereby certify that I hate prepared this application and that the work will be done in accord a�nceh�an�Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner o�licensed gent'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 sugh manner as to become subject to workman's compensation laws of California. —Coal wter�s-hiring.,6r sub-contracting signature certifies the following:"I ertify hat,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 app nt m call or req ' d in�pect on s. Completed�rraawi g everse side. N Signed date: FOR DEPARTMENT USE 6N1 LY Application Acc pted by r tt 1 1 4 bate �—/ Area_ i � Pit Grout Ins i ction bDate' �r Final Inspection bye -LL,� Date�� ti Additional Cam ants: ❑ Stk 466-6781 O"Lodi389-3621-- ___Manteca '823-7104 ❑ Tracy 835-6385 Applicant - Ratue, all copies to: Environmental Health•Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk95201 IDD A11M6UNT DUE�'�— AMOUNT REMITTED C K H RECEIVED BY DATE PERMIT`NO. t EH13-24 iREV. /e 51 � — G EH 1428 l a