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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT t 1601 E. HAZELTON AXE.., STOCKTON, CA 1 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 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.Ryles and Regulations of the San Joaquin ; Local Health District.!.. Job Address r 7 f%1/��a�c.6atr �' Clty� �` Lot Size43 X PM ' Owner's Name !/�GptctS � ?"-Address ` W Z461zGf`� �� Phone Contractor (�f �f�✓u�r�r�n/i AA(License No. Phone��3—Jb�3 W �yN Cc/ Address TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ G=am j PUMP INSTALLATION � SYSTEM REPAIR ❑ 0 HER ❑ ' DISTANCE TO NEAREST: SEPTIC TANK- SEWER LINES DISPOSAL FLO. ROP. LINE FOUNDATION �! AGRICULTURE WELL OTHER WELL ITS/SUMPS INTENDED USE TYP[E�OF WELCr=:`, PROBLEMAREA CONSTRUCTION SPECIFICATIONS u ❑ Industrial X?Opert 66ttom'1',,J7 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing J?6omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public," C1 Other ? ❑ Delta Depth of Grout Seal C� � Type pf Gro t r 13 Irrigation i 0pproz. Depth ID Eastern Surfac Seal I stalled by Repair Work Done; Ll Type of Pump .5�. H.P. State W& Done Well Destruction ? ❑ Well Diarrik r Sealina Material Itop 501 Depth { ' Filler Material (Below 60n' TYPE OF SEPTICWORK: NEW INSTALLATION,❑ REPAT/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is , available within 200 feet,) Installation will serve): Residence-_ Commercial Other `tj 7 , Number,Yaf,living units:' ,•:Wumber.,df bedrooms Character.of soil to a depth of 3 feet: "'C } Water table depth SEPTIC TANK 0! ❑ Type/Mfg • --- ----�� Capacity No. Compartments ^� PKG. TREATMENT PLT. ❑ i • x1 '!y� f Method of Disposal4 < tt Distance to nearest: Weli:, `•T Foundation I Property Line � vt LEACHING LINE 'f ❑ No. & Length of lines . . { Total-length/size W� } FILTER BED- ❑ Distance to nearest: ti Well 'F:oundatiom ( Property Line"" SEEPAGE PITS - ❑ Depth -Size - --AIumber SUMPS f ( ❑ Distance to-nearest.'751. flt/V ll Fouridatian I Property Line DISPOSAL PONDS- -_LJ "- - •. _.---.�w. i hereby certify th�tJ,have-prepared-this.,application-and-that..the work_wiil bL14 bne..iiilaccordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ` : I 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, 1 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, I shall employ persons subject to workman's compensa- on laws of California." 1�1��} �t F' mss. '�, Con ;e eS.,Th pant m call for all required ' tions. Co let drawi n.reverse side. gned OR DEPARTMENT USE ONLY / Application Accepted by ~� Date Area , f , Pit or Grout Inspection by to / 'J Final Inspectioh by Date Additional Comments: ` ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 , �:❑ Tracy $35-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO OUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. + EH 13-241REV.t/as) ' 10510 17 EH 14-26 ! to