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i� APPLICATION FOR PERMIT � (( "00 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA �I :I 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. i I { Job Address I C[ C-4 N qK City s. 4 Lot Size-- PM Owner's Name Address Phone Contractor dDV etAddress 93V-2 1 &_VttjrR License No. Phone_ 7 TYPE OF WELL/PUMP: i� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION'❑ S17STEN1-REP41R�❑"° " OTHER El DISTANCE TO NEAREST: SEPTIC TANK .' .. SEWER:LINES'. ` r DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS iNTENDED,USE TYPE OF WELL— PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ; ❑ Open Bottom E'Manteca Dia. of Well Excavation Dia..of Well Casing i 11 Domestic/Private Ll travel Pack ❑_Tracy Type of Casing Specifications) 17 Public `Other 71Delta Depth of Grout Seal Type of Grou` ❑ _ k� I I 1 Irrigation �!� -Approx. Depth l I Eastern5urface.Seal Installed by Repair Work Done ❑ Type of Pump H,P. r State Work Done_ I� Well Destruction ❑ Weil Diameter Sealing Material (top 501 I� Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I'] REPAIR/ADDITION K DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) `! Installation will serve:. Rest ence X Commercial_` Other Number,of living units: Number of bedrooms H. 3 Character of soil to a depth'of 3 feet: -.tl Water table depth SEPTIC TANK Type/Mfg 60,011996 Capacity In No. Compartments IM PKG. TREATMENT PLT. ❑ i f Method of Disposal I� Distance to nearest: Wellj" "Foundation' Property Line I i LEACHING-LINE I No. & Length of lines Total length/sizeI� FILTER BED -;-,.�, Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS Depth xSize _ Number �b SUMPS ❑ ' Distance to nearest: Well Foundation Property Line DISPOSAL-.PONDS ❑ I hereby certify that I have p4 pared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin Local Health Diltrict. i� 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 m t call for al req 'ed ins tions. Complete drawing on reverse side. Signed X Title: Date: G �I f FOR DEPARTMENT USE ONLY �! 'll. Application Accepted by Date Area Pit or Grout Inspection by II ' Date Final Inspection by I� Date t' r Additional Comments: ` ❑ Stk 466-6781 11 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 CK I FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO ..EH 13-244REV.ii H5) 7Q 701 `[•� �� (y �p�� EH 14.28 .I � �� 117 ��