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R� APPLICATION-FOR PERMIT SAN JOAQUIN LOCAL: HEALTH DISTRICT fi 1601 E, HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . (Complete in,Triiplicate), 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 incompliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations -of,the San Joaguin Local'Health District. <r - �� City 4 Lot'S¢e PM , Job Address Owner's Name Address 1220 !jar &e. \%A&NWaAhone• ?V - 1&66 Contractor JF Address &skense No. 4*- Phone TYPE OF WELL/PUMP: V NEW WELL ;K WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATI`�O��Nf�71 � SYSTEM REPAIR El OTHER Ll DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL' OTHER WELL PITS/SUMPS INTENDED USE— TYPE OF WELL .PROBLEM AREA CONSTRUCTION SPECIFICATIONS � r/ F1 Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing 'X Domestic/Private X Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other '' [--] Delta Depth of Grout Seal �JQ / Type of Grout [IIrrigation i. ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ , Well Diameter Sealing Material (top 50') Depth Fiber Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other 6 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth. SEPTIC TANK ❑ Type/Mfg Capacity _ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line Q LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line ,DISPOSAL PONDS .e.+n_t �_r, .- _��» �- :.._.� . u.- •.— _ -� 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 performance of the work for which this permit is issued, I shall not I 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.'.' , The applicant 1pust call for all req"' d inspection . Complete drawing on reverse side. ' Signed Title: Date: �6 Y crr ad.� DEPART NT USE ONLY I OR o- � 6 Application Accepted by Date Area:� 4 � k Pit or Grout Inspection by Date Final Inspection by - Dated. r Additional Comments: ! ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 . Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,.Stk., CA 95201 A FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'N0. , INFO ( + EH 13-24(REV.1/85) EH 14-28 /�7 C?C