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APPLICATION FOR PERMIT r44— SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 (f v PERMIT EXPIRES T-YEAR`FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaguin.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.S49for aewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ' Job AddressY � f" 1 ' t �� ----- City "" „ 1 " JIy Lot Size �� / '7 P,,M, �q OOwner'sName.:e-S+C1'J Lro rVr 'f'Y1 k/ � I l�`W 4one � •"l Contractor< - Address License No. Phone TYPE OF WELL/PUMP: - NEW WELL'O, WELL REPLACEMENT ❑ OESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PtTS/SUMPS _ -s-INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - ❑ industrial ❑Open.Bottom ' ❑ Manteca Die. of Well Excavation Dia. of Well Casing 0 Domestic/Private 0,Orawi Peck - ❑Tracy- -Typeof.Casing Specifications I"1 Public Ll Other.. n Delta Depth of Grout Seal _ Type of Grout_. I I br ration —Approx. Depth 1 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work _ Well Destruction K Well Diameter Sealing Material (top 50'1 L/ A Depth Filler Materia! (Below 60'1 - TYPE OF SEPTIC WORK: NEW INSTALLATION 1 T"REPAIRIADDITION Ll DESTRUCTION I I (No"pllichystern permitted it public seweir.is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedraans Character of w8 to a depth of 3 feet: - Water table depth SEPTIC TANK 0 Type/Mfg - - Capacity No. Compartments PKG. TREATMENT PLT.O .. Method of Disposal Distance to nearest: Well Foundation - Property Lina LEACHING UNE ❑ No. 6 Length of lines Total la gth/arse FILTER BED O Distance to nearest: Weill - Foundation Property Uns f SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, end rules and regulations of the San Joaquin Local Health District. Horne owner or licensed agent's signature certifies the foeowing: "1 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 hiring or sub-contracting signature certifies the following: "1 certify that in the performance of the w9rk for which this permit is issued,1 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. } Signed x `/{ xr;/}j�31. � �1. ....� - OaJ —74 ") ';a9�^� yr FOR DEPARTMENT USE ONLY r Application Accepted by Area 49 f Pit or Grout Inspection by Date Final I 'on by Date O MA s Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy e354385 Applicam - Return all copies to: Environmental Health Pend[/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMC ITTED K RECEIVED BY DATE PERMIT'NO INFO ... ... CASH #,811171 W".Il afr EN K1d