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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRr,,,r 1601 E. HAZE T ON 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 Sart 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. /� �/ ,/� /, f Job Address x-771- V !M D/1 y 5 /�� City 4-b-0-1— Lot Size PM Owner's Name _13 . DC-1 Address / 79 /!7 MAde—S� Rd— ^&phone 3-4,-V V9 ! V Contractor&FS r I17-C Address Ytib At S/}C! 0 License Nor-? Phone 36,Y3132 TYPE OF WELL FfUMP:r NEW WELL ❑ WELL REPLACEMENT r_1 DESTRUCTION C1 PUMP INSTALLATION Cl SYSTEM REPAIR 64 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ___- DISPOSAL FLD._—_- PROP. LINE FOUNDATION AGRICULTURE WELk OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS [I Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation _ Dia. of Well Casing r I pts"i*%tintptivete ❑ Gravel Pack C1 Tracy Type of Casing Specifications ('I Public ❑ Other I 1 Delta Depth of nrout Seal Type of Grout___ 1A Irrigation __ Approx. Depth I 1 Eastern Surface Seal Installed by r� -- Repair Work Done U Type of Pump uKA3111 5 H.P. _ —__— State Work Done �C M S��V C ULSC NA 1"r Well Destruction ❑ Well Diameter Sealing Material (top 501 Q�� T M-b I? I P 1`L -Ca1L__ IV R g 14 t Depth Filler Material (Below 501 P U w 0IP s -- TYPE OF SEPTIC WORK: NEW INSTALLATION I I RL PAIR/ADDITION 1 1 DESTR CTION I F (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. L7 �g Distance to nearest: Well Foundation Properly`LihfS� r _ RECEIVED LEACHING LINE ❑ No. & Length of lines Total length/sizleLLt_ n to 4nn�) FII TER BED ❑ Distance to nearest: Well _ Foundation ProppeertlyLine�! "7i �I�� ' SEEPAGE PITS 1 I Depth _ _Size _ _ __________ Number - SUMPS I 1 Distance to nearest: Well _ Foundation Property Line DISPOSAL PONDS 1.1 ' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin co ` r finances, state laws, and rules and regulations of the San Joaquin Local Health District. , 1 Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the wprk for which this}, rmit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of Califorml.. ' gntractor's hiring or Bibb-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall e y sons subject to workman's compensa- tion laws of California." 1 J7 The applicant must call or all required inspections. Complete drawing on reverse side. ll- Q Signed X Title: ee� — -LDate: FO DEP RTMENT USE ONL Application Accepted by ___ _ __ Date r Q Area Pit or Grout Inspection by _- Date Final Inspection by Date Additional Comments: - — ❑ Stk 4666791 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO �y7� EH t)-24(REV.tiM51 11 — ! �j a �. /� C ��• ' �'7" - EH to 2e VVV �l