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3. F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED r� [ m lete ill Triplicate) �t�r V , "t.. p p Application is hey made to the San Joa m 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- -• ?77 �`}' KLJt /-. c. :t: Job Address -at i Z t I It V City `�? '"rr ! Lot Size PM — ' Owner's Name ` r I r:t "I Address / ?r►� l f C - f 3"�o F 's 17' Phone 3,? f I� f Contractor SgEerk r , 'li dress ,r't`e �1 i 57-License No.r'—IL-111-1 �_ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER Pi(- 6 j;: t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE � ;► FS FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1''tr !; ❑ Industrial ❑ Open Bottom C3 Manteca Dia. of Well Excavation Dia. of Well Casing 0 Domesti0Private ❑ Gravel Pack El Tracy Type of Casing SpecificationsjA,.=f, l 1'I Public n Other El Delta Depth of Grout Seal Type of Grout I I Irrigation _..Approx. Depth l 1 Eastern Surface Seal Installed by !, Repair Work Done D Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION l 1 INo septic system permitted if public sewer is ' available within 200 leet.l 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 Al" PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. A Length of lines Total length/size +' FILTER RED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS I i Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepatAd this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and d rules and regulations of the San Joaquin Local Health Diktrict. 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."Contractor's hiring or sub-contracting signature certifies the following:"I cortify 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 must call for all required Inspections, Complete drawing on reverse side. I Signed X_ Title: t.S Data: T IF DR.DEPAfiTMENT USE ONLY Application Accepted by Data Area ' Pit or Grout Inspection by Date Final Inspection by 55r Date Additional Comments: Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7100 11Ttacy -6385 LL . Applicant -Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2OD9, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED `' CK RECEIVED BY DATE PERMIT NO. F INFO 'CASH y l . EH 13 24 IRFV.1;"51 A" ° •'�•! - ,•�C:--l