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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL .HEALTH DISTRICT ry\\ 1601 E. HAZELTON AVE., STOCKTON, CA II Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 2FROWDATE ISSUED s. (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 k made in compliance.wlth San Joaquin County Ordinance No.549 for sewage or No.+1862 for well/pump and the Rifles.and.Regulations of.the San Joaquin Local flealth'District. 1 + ft? p` Job Address �c G� nr -f c+r'. - `City' �4G "°� Lot Size .2� > ,PM "d•�' ':i� - T1s S'il . - - ;,` .,,., .- .y _I, 1] C,J4[ -. Owner's Name' e P i fe-l;e5 ':Address ��"n��—U C� - Phone Y 3 ddress j - - License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT IT DESTRUCTION ❑ PUMP..INSTALL41lON.❑ „_•. `•-`SYSTEM REPAIR ❑ _,,,_.r OTHER;❑. ;. .n• DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.;LINE 'n'FD,UNDATION 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public El Other -.;.'-.El Delta Depth of Grout Seal Type of Grout i ❑ lirigation Approx. Depth El Eastern Surface Seal Installed by Repair Work Done LI of Pump H.P. State Work Done pp 7, Well Destruction ❑ Well Diameter Sealing Material (top 50') N Depth a = -j Filler Material IBe1ow%50:i I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ,, __,�T„f,„_ayailable within 200 feet.) Installation will serve: Residence Commercial_ Other t Number of living units; = `' Number of bedrooms Character of soil.to a depth of 3 feet: j ,x Water table depth SEPTIC TANK Zi4Type/Mfg t- G n6e-f'P/ Capacity No. Compartments' PKG. TREATMENT PLT- ❑ r Method of Disposal r Distance to nearest: Well Foundation amu. — Property Line . s 't a"° :�,� _ ` Total len thlsize } ;t LEACHING LINE P-"No. & Length of-lines T t � 9 �•r,. ;�� " FILTER BED ❑ Distance to nearest: Well °�"` Foundation Property Line L �? t SEEPAGE PITS ❑ Depth "3 " Size "'i J Number h ;` CX' SUMPS ❑. Distance to nearest: ,.Well. r _Foundation Property Line M ' DISPOSAL PONDS .,. D a - -w•--,.:r..,ti---, '..'._" e a _ �•. -- �. I 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; o Home owner or licensed agent's signature certifies the following: '9 certify that in the performance of the work for which this permit is issued, I shall not k employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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- tion,laws of California." t j The applicant must call for al squired inspections. Complete drawing on reverse side. ' Signed X __ adkE Tile: ® Date- s ` R DEPARTMENT USE ONLY I Application Accepted by Date Area Q .• /� -�` k4 F` l Final Inspection by Date L� 6 Pit or Grout Inspection by Date Additional Comments: ❑ Stk 466,6781 ❑ Lodi 369-3621 ❑ Manteca 823 7101 ❑ Tracy .83,,6385 . Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,�Stk., CA 95201 FEE %0� NT DUE-_.-AMOUNT REMITTED CASH ---RECEIVED BY.• _DATE_ _ -_P.ERMIT`NO. 1NFO_.._ / G+EH 13-24(REV.1/85) _ . i��/ .• - t. ,1/2� O 5 �s �1 -- ` EH 14-26