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.ham APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZELTON'AVE., STOCKTON, CA 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 Rules and Regulations of the San Joaquin Local Health District. MS 8y- f3 Job Address S22tiJ:` " ' City Lot Size PM Owner's Name ill fir.v J+�� -- Address I: g. &1i �SaJr. S�[ICTT/Y[_L Phone t ` Contractor Address �"IF License No. ,� Phane - TYPE OF WELL/PUMP: v NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ F PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ �O� /THHER El DISTANCE TO NEAREST: SEPTIC TAMC 170 � SEWER LINES DISPOSAL FLD.J[i" PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n ❑ Industrial ❑ Open Sottom X Manteca Dia. of Well Excavation Dia. of Well Casing X Domestic/Private `Z Gravel Pack ❑ Tracy ". Type of Casing le Specifications ❑ Public r ❑ Other ❑ Delta Depth of Grout Seal Type of rout ❑ Irrigation ` _Approxi Depth ❑ Eastern,' Surface Seal Installed by Repair Work Dane. ❑. Type of Pump H.P. State Work Do e Well Destruction El` Well Diameter Sealing Material 1top 50'1 e 0. ?07 Depth Filler'Maferial IBelow 501 0. � I (P TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 71 DESTRU ION ❑ o septic system permitted if public sewer is f available within 200 feet.) Installation will serve:{ Residence Commercial Other „J M. Number-of living units:, - Number-of bedrooms" Character of soil to a depth of 3 feet-( Water table depth i SEPTIC TANK ❑ Type/Mfg` Capacity No. Compartments LA PKG. TREATMENT PLT. ❑ n Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE `, ❑ No. & Length of lines F" Total length/size , FILTER SED ❑ Distance to nearest: -Well Foundation Property Line p SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 40. ` 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. j ,t 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."i The appli ant ust call for all require nspections. Complete t rawing on averse side. , f. Signed Title: Date: f r P R DEPARTMENT USE9NLYs _ . � Application Accepted by � - '" � Date ��>�O �� Area + 1 Pit or Grout Inspection by ' to Final Inspection by Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 N0ainteca 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 +AMOUNT DUE �, AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFOCAW + EH 13-24(REV.1/55} �' 4 1 EH 1426 ` '