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n APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED IComplete 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 mede 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 5z&ejay 2b City,-sto CL69size PM Owner's Name L 1 -- Address I YVIS �~. r Phone -� t I i _C6AFkf6?s Name 6 - N- "Ucense N � "�"-1'2;zz----- _— hone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D PUMP INSTALLATION. ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE -FOUNDATdflN OTHER-WELL-- -PITS/SUMPS--..� x. INTENDED USE TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS • Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Die. of Wel Casing O Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casino Specifications ❑ Public ❑ Other Ll Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P_ State Work Done Well Destruction ❑ Well Diameter Sealing Material(top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION ESTRUCTION D (No septic system permitted if public sewer is t '` available within 200 feet.) Installation will serve: Residence— Commercial L�Other Number of riving units: Number of bedrooms fi f Character of soil to a depth�of-3 feet: /q Jr=6z)C} Water table depth SEPTIC TANK Cl Type/Mfg s lel Li Y f:r l-_ CapacNo. Compartrrrants PKG. TREATMENT PLT.❑ ,✓ .� Method of Disposal Distance to nearest: Wel 50 Foundation Property Line LEACHING LINE (goo. A Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 3--Depth Size' Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS D I hereby candy that I have prepared this application and that the work will be done in accordance with San Joiquin 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."Contractor's hiring or sub-contracting signature !eljties the f=o ng:"I certify that in the performance of the work for which this pamrit is issued,1 shall employ persons subject to workman's compensa- tion of Cef'rfomia. eppti at cefi o requ in __ . Complete drawing 227at&��_ Dato; QSigned Tide: " r ~R DEPARTMENT USE ONLY Application Accepted by -6&,Q A • Date 84. Area n -` ay 1c1 Pit or Grout Inspection by Date ?-g°u 3 Final Inspection by a -�� *- �^-- hate Additional Comments: ❑ Stk 485-Ml ❑ Lodi 369-Ml 'C] Manteca y,823-71041 ❑ Tracy 835-638.5 Applicant-Return all copies to: Environmental Heahh Permk/Services 1601 E. Hazelton Ave., P.O. Box 3009, Stk., CA 95201 INS AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMR'NQ.' . EH 13-X(R6Y.101$3) , -m- �,,-� r g q~�LJ Ifl i1,?a �