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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6761 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i , (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 whh San Joaquin County Ordinance No.549 for sewage or No. 1862 for wall/pump and the Ryles and Regulations of the San Joaquin Local Health District. 1 / ./ 0 Job Address 7 hld� -r %�P/ee //0,0D� / City �A�✓ Lot Size PM Owner's Namfe� t!r�4A06(n6�All or""tO ( mQ/" AddreDc<s J/ "12 AS Qg0✓K Phone - 3 - 214 Contractor �J.QDi✓/✓d /'/J/D/✓A// 'Address �.rGvy�1✓��y�,f'BL/� �it7 License No. Phone TYPE OF WELL/PUMP: NEWWELL______ WELL REPLACEMENT D_ESTR_UCTION ❑ —PUMP INSTALLATION N 70 .-__ .SYSTEM REPAIR-0 - ETHER.❑ _ _.___ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS lK w4ustrial�Indw"1W, ❑Open Bottom ❑ Manteca Dia. of Well Excavation 6 Dia. of Well Casing L- ❑ Domestic/Private I a Or"Pad* Id Tracy Type of Casing Fes(- Specfications ❑ Public ❑��Other ❑ Delta Depth of Grout Seal o `i'9' - Type of Grout ' - 1 '- ❑ Irrigation EApprox. Depth ❑ Eastern Surface Seal Installed by_ Kk%e^f'1/rr 4A%r c`. Repair Work Done ❑ Type of Pump /0 H.P. State Wolk Well Destruction ❑ .Well Disratsr Z Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION C DESTRUCTION ❑ (No septic system permitted d public sewer is available within 20D feet.) Installation will serve: Residence_ �'Commemial_ Other Number of Wing units:_ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to merest: Well Foundation Property Line SEEPAGE PITS ❑ 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 Sen Joaquin Local Health District. Home owner w 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." Contractors hiring or sub-contracting signature certffies the following: "1 certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant /§��cull for all req�uiired�inspections. plate drawing on reverse side. ,� Signed X - ^ ' W .1'�1LC - Title: / L'r�l '- "vat"„""°'rte Date:6E5 - FOR DEPARTMENT USE ONLY Application Accepted by P� Date Area i Ph or Grout inspection bynn / Date ��F/C� Final Inspection by / Data Additional Comments: //,P(/1(W4 5 iJ1'(10/JYPi7Li'IQP. d6eZJCf 0' dffel!' 37/J170/✓�A zn9 4(1A �3y� ❑ Stk 466-6781 ❑ Lodi 389-3621 ❑ Manteca 623-7104 ❑ Tracy 8354W5 Applicant - Return all copies to: Environmental Health Permit/Servlces 1601 E. Hazelton Ave., P.O. Box 2009, Elk., CA Vol FEE AMOUNT DUE AMOUNT REMITTEDII CK a RECEIVED BY DATE PERMIT N0. INFO CASH . EH 1}21 IRE1. EH 1L]e