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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 1 Telephone (209),466-6781 1PERMIT EXPIRES TYEAR 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 with0a laquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. _ e 4 /l 4.-1 Y_ Job Address + City t k— Lot Size X1 PM Owner's NameAddress E- f �fQy V__- - __- __ Phone Contractor Y&I ALTTT1Tt_.� Address 1 D icense No. Phone /0—S54 TYPE OF WELL/PUMP: �. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ f SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ; INTENDED USE TYPE OF WELL PROBLEM AREA: CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r ❑ Domestic/Private ❑ Gravel Pack-, ❑ Tracy Type of Casing Specifications f'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ ` i I irrigation --Approx. Depth ( I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump• H.P. State Work Done _ WellDestruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material IBelow 501 _ TYPE OFSEPTIC WORK: NEW INSTALLATIO PAIR/ADDITION t I UCTION f l (No septic system permitted if public'sewer is s available within 200 feet.) Installation will serve:' Residence=� �ammercial_ Other Number of living'units: L__ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK �� f�` Type/Mfg � '""'^'"�CTP-961ty o Compartments` I PKG. TREATMENT PLT. ❑ Method of Disposal 1 Distance to nearest: Well Foundation Property Line r LEACHING LINE W�`L4---_Mo. & Length of lines Total lehgth/size FILTER-BED Distance torest: Well Fou dation _ Property Line " ) SEEPAGE PITS l I Depth Size f Number SUMPS ❑ Distancee.to nearest: Well Foundation 'VOProperty Line DISPOSAL PONDS ❑ Yt.J I hereby certify that I have.prepared this application and that the wefk.will be done in accordance wit San Joaquin courtly ordinances, state laws, and 1 rules and regulations of the San Joaquin Local Health District. a` 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 `tertif' s the following: '9 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 alifornia." f - . f � he applicant u all for II req ed in ction o ete drawing on rayersa side. Signed Tit Date: FOR DEPARTMENT USE ONLY Application Accepted_by yI _Date. -_Area.---r� Pit or Grout Inspection by �. D FinalInspectionby Date 7 r Additional Comments: I '✓ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Appiicant_._Return_all copies_tojEnvirorlmental_Health_P_ermitLServices 1.6011._Hazelton.Ave.,_P_.0..-.Box..2009,_Stk.,_CA 95201...-- r 4 FEE INFO AMOUNT DUE AMOUNT REMIT-TED CASH. RECEIVED BY DATE PERMIT'NO. + EH 13.241REV.tiH5) , DO 5 ��j q {� Q �} �,f EH 14-28 �4 2�J... �'V ��L��O� U ��L 1�