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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT p 1601 E t-HAZELTON AVE:, STOCKTON, CA Telephone 12{19) 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 Rules and Regulations of the San Joaquin Local Health District. Job Address City _ Lot Size PM ' Owner's Name A4 L.C-,7- Address 3'"1-1!!F Phone 9V9"r/dV .Contractor F"JI 7 E1 Wd0> Address GD.S Al, 4-ILL 64AI "go" License No._ d , L7f� , Phone 4 3 97/ { TYPE OF WELL/PUMP: NEW WELL ❑ `n WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ t , , SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER°LINES DISPOSAL FLD. PROP. LINE �. r FOUNDATIpNAGRICULTURE"WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1Industrial E3Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by -- --. Repair Work Done ❑ Type of Pump H.P. yState Work Done d Well Destruction ❑ Well Diameter Sealing Material Itop"501 , r Depth Filler Material (Below 501 �� s i TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION)r DESTRUCTION ❑ (No septic system permitted if public sewer is r available within 200 feet.) installation will serve: Residence_ Commercial— Other 4 Number of living units: Number of bedrooms e [� f Character of soil to.a depth of 3 feet: -Water table depth SEPTIC TANK L1Type/Mfg Capacity µ' No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal # Distance to nearest: Well Foundation Property Line r s LEACHING LINE l No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Ser! Foundation _4- Property Line SEEPAGE PITS ; Depth Size 3 'r i" " Number j SUMPS 0 Distance to nearest: Well /40 1" Foundation ' Property Line �t 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. r , Home owner or licensed agent's signature certifies the following: "I certify that in the'performaiice of the work for which this permit 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,I shall employ persons subject to workman's compensa- tion laws of California." { i The applicant must call for all required inspections. Complete drawing on reverse Signed �-1' fil°/b-s r� Title: `� i- t 'Date: 2- Z �� R ! 1FDLEPARTMENT USE'ONLY Od ation Accepted by Area 0 f Grout Inspection by - Date n�T Final Inspection by ` pate "�onal Comments: ❑ Stk 466-8781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 A Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,'Stk., CA 95201 INFO 'AMOUNT DUE T AMOUNT REMITTED GA RECEIVED BY DATE �.t PERMIT'NO. + EH13-24(REV.1/8 5) 7 EH 1428 �� : S �. - �� Fr7 37__;-