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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601"E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 �i 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.54.9 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. X4.7" l ... ti?i5- �(1•t:"_ r� .F.+±1. 'f:. °:4 I>. � '.1 Job Address a4�lJ�CJ `F: 1� --�rY?:1C�(i1 g�'� •�. .' ty —. "t /�Ctt%! L Ci Lot Size _ PM - Owner's Name N I G�C _ sa yyCe- Address ,� ( Ph( 4,2, Zb 4p Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION PUMP INSTALLATION D ` SYSTEM REPAIR ❑ OTHER D DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — DISPOSAL FLD.�...--- _PROP_._LINE _ �r _ - FOUNDATION ��AGRICULTURE WELL OTHER WELL__-__ PITS/SUMPS \r 'INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION'SPECIFICATIONS r O;industrial C Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing _ U Domestic/Private J Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout U Irrigation _�_4pprox. Depth R.Eastern Surface Seal Installed by Repair Work Done C Type of Pump H.P. State Work Done_. I Well Destruction Well Diameter Sealing Material (top 501 Depth Filler Material(Below 501 YPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION Li DESTRUCTION U INo septic system permitted if public sewer is j; available within 200 feet.] installation erve: Residence_. Commercial Other i - Nunm er of living units. " Number of bedrooms Character of soil to a depth"of 3 e _Water table depth SEPTIC TANK U Type/Mfg Capacity__- No. Compartments PKG. TREATMENT PLT-❑ ij Method of Disposal f Distance to nearest: Well dation Property Line I — � r LEACHING LINE ❑ No. & Length of lines _ ngth/size _ FILTER BED U Distance to nearest: Well Foundation— Pro Line _ s i li SEEPAGE PITS ❑ .1 Depth Size — Number SUMPS ❑ ,Distance to nearest: Well Foundation Property Line �2 r 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, rules and regulations of the San Joaquin Local-Health District. f 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.wbich this permit isissred,I shall employ persons subject to workman's compensa- tion laws of California." 11. n { A The'applicant must for all r quired in tions. Complete drawing on reverse side. . Sig X �Z — yTitte; p 1 Date: �Z3L FOR DEPARTMENT USE ONLY Llt Application Accepted by _ .r Date Area •G I C Pit or Grout Inspection by Date_.... Final Inspection by �q Date.. r Additional Comments:�� •- ^'�" - - ,-'---' - - -�_._.. ` F1 Stk 466.6781 Ll Lodi 3633821 ❑ Manteca 823-7104 ..❑ Tracy 835-6385 - Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO XJAf'MOUN7 DUE $QAiMOUNT REMITTED CK RECEIVED BY DATE iPERMIT NO. + +EH 1324 IREV.- ��i g; W v-- • �J �{., 4' EH 14-28,1 �