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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT J f 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES') YEAR FROM'.DATE ISSUED - �-•. �ZS7' �j- " 4 tau-1 0_0 (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 Sen 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. �« 2 t Job Address Y' s 7jv,�(. ,;� S'pz A,O -t240— (2 . ,l ` '" �/ uv �Caih Lot Size PM Owner's NameT ...vrc.c.a� Address �� r/'� G V� t �� hone -� //7 Contractor's Name 1 ' ansa No./f0,.��.3r{7 3 TYPE OF WELL/PUMP: Phor>� J ` NEW WELL ❑ WELL REPLACEMENT ❑/ DESTRUCTION ❑ - /• PUMP INSTALLATION ❑ " SYSTEM.REPAIR�Cfl , OTHER ❑ ' DISTANCE TO NEAREST: SEPTIC TANK SEWER.LINES - •,5,= v DISPOSAL FLD. PROP. LINE +. FOUNDATION .AGRICULTURE WELL '� OTHER'WELL ' PITS/SUMPS N INTENDED USE TYPE,OF WELL PROBLEM AREA` CONSTRUCTION SPECIFICATIONS _ ❑ Industrial ❑ Open Bottom ❑ Manteca • Dia. of Well Eicavation rJi ❑ Domestic/Private e - Dia, of Well Casing ❑ Gther Pack ❑ Tracy Type of CasingLby Specifications ,ra Public ❑ Other ❑ Delta Depth of,'Grout } { j Type of Grout '\� Ir�lrrigation _ _Approx. Depth ❑ Eastern } Surface Seal Ins Repair Work Done GK Ty m of Pump ,fi. � y H.p. �o Q� ork Done/ ' WellDestruction O Well Diameter Sweating Material (top 50'1 . Y. \Depth _ I Filler Material(Below 50') TYPE OF'SEPTIC'WORK-NEW-INSTALI71710N-❑"'REPAlR7ADDIT1bTli❑' DESTRUCTION ❑ INo septic system 1 permitted if public sewer is.\il t available within 200 feet.) Installation will serve: Residence— Commercial_ Other 1 Number of living units:_ Number of bedrooms ( �� Character of soNao,o depth of 3 feet: Water table depth SEPTIC TANK ElType/Mfg I CapacityNo. Compartments PKG. TREATMENT PLT. [3r ` Method of Disposal Distance to nearest: Well Foundation Property Line I F` — LEACHING LINE ❑ No. & Length of lines Total length/size. ..1 6 FILTER BED ❑ Distance to nearest: Well Foundation I. Property Line k! SEEPAGE PITS ❑ Depth IA.. Size Number �� SUMPS ❑ Distance tb nearest: Well Fo ndation DISPOSAL PONDS ❑ _ ' Property Line I hereby certify that I have prepared this eppllcation and that the work will be done in accordance with San Jo0uin county ordinances,state laws, and rubs 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'"' iring or sub-contracting signature certifies the following:"1 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." }, %/ tt The applicant t cal for all requ '_spections. Complete drawingj�re�verse sid,e. Signed Xtb:,f,�� 1 � Date: �( �t/� FOR DEPARTMENT USE ONLY �/ Application Accepted by �L —.�_`•vhf' r Date �i�/ 7 r e Area //� p Ph or Grout Inspection by V + Date Final Inspection by Date f7"�34J y Additional Comments: ❑ Stk 466-6781 ❑ Lodi W9.36 1 ❑ Manteca 823.7.1Q4 ❑ Tracy 835 -6385 Applicant- Return all copies to: Environmental Health Pem1h/Services�1601-E. Hazelton Ave., P.O. Box-2D09, Stk., CA 95201 NFO AMOUNT DUE AMOUNT REMITTEDCK RECEIVED BY CASH GATE PERMIT"N0. ♦ EN 11-M iii V ,a1.1 C _