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L APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 �d`{ i�i CAY'TC r 13d, City 259 AZ0Ao' Lot Size "01" PM Owner's Name Toe 1Pey,.wi, ,,? Address Z lO_-,x lA• Gs�i rPa� flet! Phone Contractor A6qV5b,,V Address rT Ldp J+ ! License No. Phone TYPE OF WELL/,PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER LJ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I 1 Irrigation _Approx. Depth hI Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done v.. Well Destruction ❑ Well Diameter Sealing Material (top 50'I Depth f Filler Material (Below 50"'A ". r 0 TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITIONX DESTRUCTION I 1 INo septic system permitted if public sewer is `) I available within 200 feel.) 1_ Installation will sere: Residence I—%Commercial— Other Number of living units.' I Numbe„of bedrooms Character of soil to a depth-of 3 feet: L Water table depth SEPTIC TANK ❑ l Type/Mfg i { Capacity No. Compartments r PKG. TREATMENT PLT. ❑ 1 i� ;,� V� r _ Method of Disposal Distance to nearest: C Well s Foundation Property Line t LEACHING LINE L1 No.'&+,Length of lines Total length/size 1 �° Ld, 1 FILTER BED ❑ Distance=tonearest: Well Foundation Property Line SEEPAGE PITS )0 Depth .ZJSize MAI Number j SUMPS L� Distance to nearest: Well6C!3 ` �._�-__.... Foundation Property 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 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," The applicant muV call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: 3-6_90 FOR DEPARTMENT USE ONLY f Application Accepted by ` pate – – Area ` 7 Pit or Grout Inspection by _ Date Final Inspection by Date Additional Comments: G � Z�11.�6 ❑ Stk 466-6781 ❑ Lodi 369-364'1 ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED ' CASH, RECEIVED BY DATE PERMIT NO. i EH 13-261REV.tix51 L41� EH 16.29 (D 4 /� fl rJ+