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/ fill APPLICATION FOR PERMIT . f�( 10 '' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) I h/ Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein doscribed. s 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. ,^, `/A Job Address 1I 1 uuW M°T le,a o CT City - 691A. Lot Size PM Owner's Name J (in RO19 f 1%C50 A! Address Phone 838 4404-74 /1M CAnt.r(C ISo 13vfToN Qyf Lice rise No.2yal7$ Phone Z365EIY Contractor Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION..❑ SYSTEM REPAIR ❑ .c OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F.LD. PROP. LINE FOUNDATION AGRICULTURE WELL _ OTHER WELD PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I - ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wall Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications \ rl Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout_. \ I I Irrigation —Approx. Depth 1 I Eastern Surface Seal Installed.by _ \ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 -. Depth Filler Material (Below 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION (.I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other ) ; Number of living units: _ Number of bgrooms Character of soil to a depth of 3 feet: M+ON L o A^ Water tabte depth SEPTIC TANK e Type/Mfg f C_a_pac_ity, I q 00 N0 No. Compartments PKG. TREATMENT PLT. ❑ .. r 1 Method of Disposal Distance to nearest: Well 1 LW Foundation-_10 Property Line 1 SO LEACHING LINE EK-No. & Length of lines 2 /001 Total length/si I001 FILTER BED ❑ Distance to nearest: - Well Foundation - Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation - Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin 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 performanceofthe work for which this permit is issued, I shall not employ any pgison in such manner as to become subjeppgto workman's compensation laws of California." Contractors hiring or sub-cgntracting signature certifies the following:"I certify that in the performancEf 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 inactions. Complete drawing on reverse side. Signed Title. QJUA'a e4-'-, Date: , 1• ,� 8� FOR DEPAR ENT USE ONLY Application Accepted by r Dat - - res - f Pit or Grout Inspection+hy Date Final Inspectiony r Additional Comments: . U ❑ Stk 466-6781 0 Lodi 36.9-3621 0 Manteca 823-7104 ❑ Tracy 83 „^^ Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Aye., P.O. x 2009,Stk. A 95201 FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BV DATE PERMIT'NO. INFO �1 a EH M24(REV.1/851 D 1/ / / � EH 14-28LLL t/ !!!