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r ��t` 1. '�y,.• � s � \ ��~'� �� t',� I 1 APPLICATION FOR PERMIT y 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) 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 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. Job Address2,0 r✓i-a 0a Vis AO), City_/W/ Lot Sae /70 PM_ �{ fs ' • r °�`� LI /I- 9so 21J/JQ 7jFPhorap—Owners Name 7 5 — Contractor AtJ�Y X ddressgaG icense No. 3��J Phone�c� 4611, TYPE OF WELL/PUMP: NEW WELL/ WELL REPLACEMENT 0 DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER J DISTANCE TO NEAREST: SEPTIC TANK &Q'* SEWER LINES J00 '4-!t_ DISPOSAL FLD�*' PROP. LINE � D FOUNDATION -�- AGRICULTURE WELL/ ` OTHER WELL & _ PITS/SUMPS /60 C., INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial _ ❑ Open Bottom ❑ Manteca Dia. of Wei Excavation Dia:of Well Cash$ Vbomestic/Private Gravel Pack ❑ Tracy Type of Casing �� Specifications C/aSS-160 O Public ❑ Delta Depth of Grout Seal �0 Type Grou I ❑ Irrigation J,#_V�Approx rDep,,h vl l Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump { H.P. - State Work;Done Well Destruction ❑ Well Diameter V Sealing,Material (top 50') f Depth Filler Material{Below 501 i. TYPE OF SEPTIC WORK: NEW INSTALLATION ❑i REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system,permitted if public sewer,is i t available within 200 feet.) Installation will serve: Residence_ Commercial _Oth_er` Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:�_ \ Water table depth SEPTIC TANK _17 ,Type/Mfg. Capacity No. Compartments PKG. TREATMENT PLT. C Method of Disposal Distance to nearest: Well _ Foundation r Property Line_-- / LEACHING LINE ❑ No. & Length of lines Total length/size _ FILTER BED ❑ 'Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS C Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C I 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. r, 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 hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit Is}sued,1 shall employ persons subject to workman's compensa- tion laws of California," The applicant must call for all requi d ins coons. Complete drawing on reverse Ida. �l (� Signed X_yyr t� Title: C~G3? Sfr1 r date: F DEPARTMENT USE ONLY 7 Application Accepted by Date�� Area Pit or Grout Inspecti Date t1 Z� «Final Inspection by Data Additional CommentA4Nnrr , ❑ Stk 466-6781 ❑ Lodi 389-3821 ❑ Manteca 823-7104 racy Applicant-Return all copies to: Envirormtental Health Permit/Services 1601 E. Hazelton Ave., P,O. Box 2009, Stk., CA 95201 FEE 5 INFO 0,-0 aAMOUNT OUE "� AMOUNT REMITTED 'CASH RECEIVED By �f DATE PERMI/T�''NyO. EH 14-2 (flEv.7/BS) l EN 141e V r illi.{{{{��' V Q1(✓r' J