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f APPLICATION TOR PERMIT I i• Y' SAN JO46LIiN LOCAL HEALTH DISTRICT 1601 E. yHAZELTON AVE., STOCKTON, C4,, Telephone 1209) 466-6781 - PERMIT EXPIRES 1,YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heieby 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 Oistrict. �X 9 P119 Job Address City Lot Sized"[. PM_69 �y 401- Owner's Name Address Phone — '/ i Contractor No. one r I TYPE OF WELL/PUMP. NEW WELL 11WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ..- DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FL PROP_ LINE FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' ❑ Industrial ❑Open Bottom [I Manteca Dia. of Well Excavation " Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public fl Other Cl Delta Depth of Grout Seal Type of Grout I I litigation —Approx. Depth I 1 Eastern Surface Seal Installed by - Repair V1 rk Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 5501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW IN7z, N I REPAIRIADDITION l I DESTRUCTION I.) (No septic system permitted if public sewer is j available within 200 feet.1Installation will serve: 'Resldenetmmercial_ Other _ — Nurn er of living units:,� Number of bedrooms—f— Character of soil to a depth of 3 feet: afar table depth SEPTIC T K ,0 Type/Mfg Capacity ' NZ"'Cbinpartments PKC. TAF PLT. ❑ / �7r, y� fuiethod of Di I Distance to nearest: Well0._ Foundation ✓ t% _ Property Line LEACHING LI 1❑ -No. & Length of line Total length/size _ FILTER BED ❑ Distance ta'ilbarest: Well _ Foundation __ .<Z Property Lina I SEEPAGE PITS 1 1 y Depth Number t Ll Distance to nearest. Well V Foundation, Property Line ' DISPOSAL PONDS ❑ h I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,stale 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,I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's airing or subcontracting signature certifies the following:"I certily that in the performance of the work for which this permit is issued,I shall employ pirsons subject to workman's compensa- tion laws of California." 1' The applicant u t cal r al requir in ctions. Complete rowing on r se side. Signed Tilts: �� --� - - Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Are. Area �J Date Pit tsr out inspection by Data Final In spection by- Additional omnf5nts: t:n�✓— ❑ Sik 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑Tracy 835-63x5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2000, Stk., CA$5201 FEE AMOUNT DUEAMOUNT REMITTED CASH RECEIVED BY DATE PERM17'NO. INFO 1 a EH 134A IREV,1/95) EN t4-2tl f7 L1