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APPLICATION FOR PERMIT II SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6761 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) t 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 i 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 l' Local Health District: - J1 Job Address „ `� ' 6A0 Chy-PSFaJ.-!) Lot Size PM 11 1 I' Owner's Nam a n Ve-� 4'o IIA Address on Phone 1f, Contractor- --' "-�/� Address - - ---- _. �-%. - License No.'Phone .- Phone 1 TYPE OF WELL/PUMP: NEW.WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 4 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL FLD. PROP. LINE ( FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS. ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.of Well Ekcavation Dia.of Well Casing ` ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy,� '„ -Type of Casing Specifications (. ❑ Public { ❑ Other 1 ❑ Delta Depth of'Grout.Seal Type of Grout i( ❑ Irrigation F --Approx. Depth Ll Eastern Surface Seal Installed by V Repair Wark Done ❑ Type of Pump H.P. State Woik Done r � Well Destruction ❑ Well Diameter Sealing Material (top 60') _ Depth ( Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEIN INSTALLATION iff REPAIR/ADDITION ❑ DESTRUCTION O (No septic system permitted if public sewer is '/ available within 2(70 feet.) i l Installation will serve: Residence f✓ Commercial— Other. Number of Irving units: Number of bedrooms -� Cha'ractar of-soil to a depth of 3 feet: ' Water table depth SEPTIC TANK ❑ Type%Mfg apacity _ No. Compartments e PKG. TREATMENT PLT.❑ j, lei y Method of Disposal v C Distance to nearest: Well Foundation.fns Property Line LEACHING LINE ❑ No. & Length of lines �' !{(� Total length/size ( r FILTER BED ❑ Distance to nearest: Well Foundation Property Line I I SEEPAGE PITS C1 Depth! 10Size Number q �+ SUMPS ""` ❑'Distance to hearei;C 'Well _" Foundation Property Line_t�7-_—' DISPOSAL PONDS ❑ (.hereby certify that I have prepared)this4pplication and that the work will be done in accordance with San Joaquin county ordinances, state laws,and rules and regulations of the San Joaqui&tocal 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-ds-to-become'subject to workman's-compensation laws of California.".Contractor's hiring or subcontracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compenae- tion laws of California." 1 The applicant must call for all required inspections. Complete drawing on rev/elrile Side.. Signed ._ .1 , • Tige:�hFr3 �vl.'I ._ Date: r � FOR —DEPARTMENT USE ONLY �S Application Accapted by r - Date V Area 046 Pit or Grout Inspection by � Date Final Inspection by bate3-1171_87_ Additional Comments: ' ❑'Six' 48&6781 --13 Lodi 3633621 -'❑ Manteca 823-7104 ❑ Tracy 835-63% Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P:O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE .t AMOUNT REMITTED CASH RECEIVEp aY'� DATE PERMIT N0. NFO EH13-24 MM t i a 6) Zin,0 ��b g Z?7