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F a,• APPLICATION FOR PERMIT z 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. `' Job Address /+y O"� � /- ---�-�,lr ��F S / Ciry Lot Size PM Owner's Name V 1Q F Y YV &c1c1ress 11 Phone Contractor T PR Li'l•- Address �� r -) Ql' 1**fQLJLicense No_ _ - Phone R TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll "PUMP INSTALLATION F1 SYSTEM REPAIR ❑ OTHER C1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FI.D. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ J INTENDED _USE TYPE OF WELL 'PROBLEM AREA 'Dia. of U SPE TF(CAT16N5 ❑ Industrial ❑ Open Bottom J Manteca ` Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (1 Public ❑ Other �rl�Delta-DPt Grout Seal Type of Grout I I Irrigation - _Approx. Depth I 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump - i -H.P:' " _ State Work Done_ Well Destruction ❑ Well Diameter -r-- Sealing Material Itop 50'1 Depth } Filler Material (B,Itt,,50.1 TYPE OF SEPTIC WORK: NEW INSTALLATION I-I REPAIR/ADDITION I TRUCTION available available Thin 200 feet.) it public sewer is 1 � I Installation will serve: Residence_ 4Commercial y�r vlher f Number of living units: _ Number of bedrooms ( - Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK hype/Mfg r C 8-00 C r E {.lh- Capacity f X=L—,l No. Compartments PKG..TREATMENT PLT..❑r / „S .Method of Disposal r� __ " fr - (�_t.r Distance to nearest: W811:�(ZlL Foundation; PropeM.Line r ;LEACHING LINE:4 ,l C1'f l Total length Len Length of lines } r /size g �: v FILTER BED ❑ Distance to/serest: - Well '4" Foundation Property Line i SEEPAGE PITS. t-i Fi� I Depth r^• - Size Number SUMPS- ❑ Distance to nearest: IWell1 Foundation Property Line DISPOSAi PONDS'1-:'0 'j t - r ' ` k 41 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 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, 1 shall not .- employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature icertlF a 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- I Ywn laws al8ornla" , Theppap�plica t u ca ,tor I re 'red plate drawing oryfeveree w Sig l'�' tt Title: l/- -� Date: 7 MIFID EPARTMENT USE ONLY Application Accepted by 'r ( Date Area /0 c- �o----- 9 30 Pit or Grout Inspection by Date Final inspection by Date Additional Comments: ❑ Stk 466.6781 ❑ 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, Stli CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASN RECEIVED BY DATE PERMIT NO. INFO �'rn1 n�1Int q-3z 0 fj ..EN Wit IIi I'll C1 V v t„� " ` ��