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: 51' # APPLICATION FOR PERMIT , rt , SAN JOAQUIN LOCAL HEALTH DISTRICT, 1601 E. HAZELTON-AVE_ STOCKTON, CA Telephone (209) 466-6781 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 instalr 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 Local Health District. o- Job Address cit F .04Aof Size PM - Owner's Name ///+1 eS.-v Address Phone Contractor Atz _ Addressc License N v1`�' �+� Phone TYPE OF WELL/PUMP:; NEW-WELL El ,-�WELL REPLACEMENT-0 DESTRUCTION LJ,'.' f PUMP INSTALLATION ❑ `' % 'r STEM REPAIR ❑� A OTHER ❑ - 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 ❑ Industrial ❑ Open Bottom I] Manteca Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ' ❑ Public 171 Ofher' Fl ' r-" Depth of Groufeams •SType of Grout - I I ] Irrigation _.-Approx. Depth I k Eastern Surface Seal rnstalled-by Repair Work Done ❑ Type of.Pump H.P. i State Work Done Well Destruction ❑ {Well Diameters Sealing.Material (top 50'1 '? r� Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION-1 1 DESTRUCTION l 1 INo septic system permitted if public sewer is / 4 available within 200 feet.) Installation will serve: Residence L Commercial Other Number of living units: Number of bedrooms_ ' 'r .- 1 77 Character of soil to a depth of 3 feet: Wateit"ahle depth -� SEPTIC TANK ❑ Type/Mf I. - '; 9 Capacity.__ No. Compartments PKG. TREATMENT PLT- ❑ k= I '� •- Method of Disposal Distance to nearest: Well ��ou dation - 2� Property Line rIJ/{/� I j J Fu LEACHING LINE )i No. & Length of lines — Total length/size FILTER BED ❑ Distance to nearest: Well /4232t Foundation �� Property Line � , R SEEPAGE PITS 11 Depth I Size Number h� SUMPS ❑ Distance to nearest: Well' FoundationProperty Line DISPOSAL PONDS ❑ , 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, and rules and regulations of the San Joaquin Local'Health District. + Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permitisissued, I shall not employ any person in such manner as to become subjecuto workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performanc6 of the work for which this permit is issued, i shall employ persons subject 6,Nwork-man.'s compensa-. tion laws of California." The applicant must call to II required inspections. Complete drawing on reverse side. r� Signed Title: Date: *I R DEPARTMENT USE ONLY. F Application Accepted by r (Dat&J L.s 4 ( 6 Area r Pit or Grout Inspection by Date Final Inspection by Date Additional Commenty ❑ Stk 466-6781 F) Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy, 835-6385 Applicant- Return all copies'to: Environmental Health Permit/Services 1601 E. Hazolton Ave., P.O. Box 2009, Silk., CA95201 FEE INFO AMOUNT DUE AMUUNT'R,EMITTEDCrCASH RECEIVED BY DATE PERMIT NO. ..,.- .Etk13-241RiV_i s� �.a..., -. =o - - �m- .•+•�jt.�------,-•.-� ��.,..,_.... ,} ~EH 14-28