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r - APPLICATION FOR PERMIT. W' j "I (� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E..HAZELTON`�4)E„ STOCKT0N, CA " Te phone !20911'466-fi781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate)VIO?oiaAL1110ES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein kl"IIMF. Eapplication 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 Distric } ti* %'/A . Y —! �r�OJ iJ�CI 7 r;+., T.-A�'l�/C•iiEl-yf 1/ r c;'o PRA I hereby certify that I have prepared this application and that the work will t rulesand reguI do f the San Joaquin Local Health District. •t Home owner icensed nt's signature certifies the following: "I certify t1 employ a pars in such anner as to beco subject orkman's comK cert he folio ng: "! ce fy at'in th pe r ce ft e w hick tion t s of Califo nia.'= The pplica'nt mus cat) al require -,ins plate- rawing-on ,r Sign X Title- -- ---- itle:r-- FOR' DEPARTM Application Accepted by Pit or Grout Inspection by Date done in accordance with'San Joaquin county ordinances, slate laws, and in the perfo'rmbnce-of the work for which this permit is issued, I shall not lsation laws of Califotnia Contractor's hiring or sub -contracting signature ii rmit is issued, I shalll employ persons subject to workman's commpensa- A� Date: JT USE ONLY Date Area Final Inspection by Date _/1.2- Sr Additional Comments: ❑ Stk 466=8781 ❑ Lodi 369-3621 ❑ 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 +. EH 13.24 (REV. 1/ 8 5 EH 14-28 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH 6 Owner's Name rs 4L_/Address Phone IS,a ' ! C� Contractor Address l E License No. A7 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE I TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 0 Open Bottom ❑ Manteca Dia.-ofWell Excavation Dia. of Well Casing ElDomestic/Private ElGravel Pack ❑Tracy Type of Casing Specifications FI Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx.pDept 1 I E stern Sriace Seal Installed by _ Repair Work Done Ll Type of Pum H.P. f/ State Work Done E Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth filler Material (Below 501 TYPE, OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION 111 DESTRUCTION I 1 (No septic system permitted if public sewer is + ! available within 200 feet.) Installation will serve: Residence _ - Commercial — Other j Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Cl Type/Mfg !Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well FourFdation Property.Line I LEACHING LINE ❑ No. &Length of lines I •otal length/size FILTER BED _ k - , ❑ Distance to nearest: Wellb 'Foundation Property Line SEEPAGE PITS II Depth Size P -Number ^ ^ SUMPS r UI Distance to nearest: Well Foundation s Property Line DISPOSAL PONDS 11,'t V" I hereby certify that I have prepared this application and that the work will t rulesand reguI do f the San Joaquin Local Health District. •t Home owner icensed nt's signature certifies the following: "I certify t1 employ a pars in such anner as to beco subject orkman's comK cert he folio ng: "! ce fy at'in th pe r ce ft e w hick tion t s of Califo nia.'= The pplica'nt mus cat) al require -,ins plate- rawing-on ,r Sign X Title- -- ---- itle:r-- FOR' DEPARTM Application Accepted by Pit or Grout Inspection by Date done in accordance with'San Joaquin county ordinances, slate laws, and in the perfo'rmbnce-of the work for which this permit is issued, I shall not lsation laws of Califotnia Contractor's hiring or sub -contracting signature ii rmit is issued, I shalll employ persons subject to workman's commpensa- A� Date: JT USE ONLY Date Area Final Inspection by Date _/1.2- Sr Additional Comments: ❑ Stk 466=8781 ❑ Lodi 369-3621 ❑ 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 +. EH 13.24 (REV. 1/ 8 5 EH 14-28 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•NO, X.) f WN R 3 J0