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APPLICATION FOR PERMIT ; SAN JOAO,UIN,LOCAL HEALTH DISTRICT ` 1601 E. Hl ZELTON AVE., STOCKTON, CA Telephone 1209)466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete inTriplicate) Yf". 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 '�__ � C.-� f Address.C- r - ' Phone Contractor—'7`l 1 FUL�-Ei� -:Address "' '�•� ' 3 License No.� Phone TYPE OF WELL/PUMP: l NEW WELL 1] } WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION i = SYSTEM REPAIR ❑ OTHER ❑ DISTANCE 7Rf6 SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FL~O DATJON AGRICULTURE WELL OTHER WELL l i INTENDED USE 1. -TYPE OF WELL ' P,FfU E�4 CONSTRUCTI CATIONS ❑ Industrial ❑ Open Bottom r ❑ Manteca Well Excavation Dia. of Well Casing Y .• I ❑ Domestic/Private ❑ GraveiiPack. f ❑ T cy Type of Casing Specifications ❑ Public 1 ❑ Other , t C] Delta Depth of Grout Sea Y oType of Grout ❑ Irrigation ° h + pp�ox. Depth' ❑'East`ern �; Surface Seal Installed by ti �s " Repair Wor eJ O iTyp of Pump '` H:P. t State Work Done W estruction 12 Well-Diameter 1 Sealing Material {top 50'1 I IDepth { Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is _�_" J t k e available within 200 feet.) Installation will-64., Residence z Commercial Other 4�&�txovz V4 4e— IPA 1✓ , Number of living units: } Number of Bedrooms i Character of soil to'a depth of 3 feet: A Via 3 t,— ater•table-depth— SEPTIC TANK a ❑ Type/Mfg ?" j s Capacity No. Compartments ' PKG. TREATMENT PLT. ❑ I E t�., Method of Disposal - Distance to nearest: Well y I Foundation Property Line LEACHING LINE No. & Length of lines Total length/size y r t ! FILTER BED 1' Q. Distance to nearest: Well "F' rFoundation Property Line ? !: SEEPAGE PITS ❑ Depth Size Number SUMPS El Distance to nearest: V1/ell [ Foundation Property Line DISPOSAL PONDS ❑ i l 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. l' 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 ; l 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,1 shall employ persons subject to workman's compensa- tion laws of California." ; The applicant must call for II req fired inspections. Complete drawing an reverse side. i " Signed e` r Title: cs;v Date: FOR EPARTMENT USE ONLY Application Accepted by ! Date Area h S 2 Pit or Grout Inspection by p Dat Final Inspection by `�'�®®-� Date -- �I Additional Comments: /} Orst✓ x, �L �WWij ❑ Stk 466-6781 ❑ Lodi 369-36211 00 Manteca 823-7104 ❑ Tracy 835-6385 ,4 ; 1%4"; Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ' IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. + EH-13.244REV:1/85) £H 1425 ;•