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I IR APPLICATION FOR PERMIT ;� v t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ih Telephone (209) 466-6781 11 PERMIT EXPIRES 'I'YEAR FROM DATE ISSUED .. I (Complete in Triplicate) �l 4 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 t Local Health District. jl Job Address WZ7XEe4zn5 9D City Lot Size IPM p Owner's Name . Phone II •b Contractor /J�'��L /9Address GU icense No. fi ,E" Phone TYPE OF WELL/PUMP: NEW WELL,Nf WELL REPLACEMENT DESTRUCTION ❑ i` C PUMP INSTALLATION-A SYSTEM REPAIR ❑ OTHER ❑ i? J DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. � PROP. LINE rr FOUNDATION AGRICULTURE WELL 1 OTHER WELL PITS/SUMPS tcai-r- I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSoi— Or ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation �i� Dia. of Well Casing Domestic/Private I>'Gravel Pack E) Tracy Type of Casing >�t- Specifications .� ('I Public Cl Other ❑ Delta Depth of Grout Seal- f Type of Grout _ IIJN I I Irrigation II Eastern 5/u�ace Seal Installed by �i/� Repair Work Done 11 Type of Pump H.P. f /Z- .._.- State Work Done _ n Well Destruction ❑ Well Diameter Seating Material (top 50'1 1! Depth Filler Material (Below 50'1 _ TYPE OF SEPTIC.WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I i DESTRUCTION I 1 Mo septic system permitted if public sewer is +r available within 200 feet.) Installation will serve: Residence— Commercial Other , II Number of living units: Number of bedrooms �" II Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK = ❑,_J e/Mf 6 a " Yp 9'�' Capacity _ No: Compartments 'k PKG. TREATMENT,PLT. ❑`Y. Method of Disposal - Distance to nearest: Well Foundation -t^ Property.Line '� LEACHING LINE, ❑ No. & Length of lines Total length/size p FILTER BED ❑ Distance to nearest: Well Foundation 0Property Line SEEPAGE PITS 11 Depth Size Number ¢ SUMPS LZ Distance to nearest: Well Foundation w-S property Line * i° DISPOSAL PONDS ❑ TM a- r jj I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordihances, 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 pertormance of tie work for which this pe nrt.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-issued,1 shall employ persons subject to workman's compensa- tion laws of California." may. e r The applicant fo all retions. Complete drawing on revers ode. '� {.. ` Signed X_ OTitle: �» Y- %%1 �� Date: FOR DEPARTMENT USE ONLY j sl r� Application Accepted by Date Zb Area V I 4-/,/ E1• Pit or G-, r"�out Inspection by W' QDate(� _inal-Inspersion_by_ _ F Date - --. Additions! Comments: O-rJ ' �� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7 04 ❑ Tracy 835-6385 Applica t - Ret �urn all copies to: Environmental Health Perrnit/Services 1601. E. Hazelton Ave„ P.O. Box 2009, Stk., CA 8520 it � INFO AMOUNFEE T DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•NO. ♦ EH 13-24(REV.'fiHs)EH 1 4-26 r JS_ _ '15