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'tom APPLICATION FOR PERMIT, 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. 1$6'1 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. - . t,`,} �+P�a I IJ _`O-SO—SG i Job Address -City Lot Size PM Owner's Name L Address aD f :SF ON 10A) g�a_ Phone ., ,�, -.Contractor. �E )LLtN �-Address_ t (-.._ .- .... License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL`REPLACEMENT..0- "+" DESTRUCTION ❑ a f+ PUMP INSTALLATIO( ' '�SYSTEM REPAIR'❑ OTHER ❑ _ DISTANCE TONSEPTIC TANK � SEWER LINES f r4 iT]1SPOSAL FLD�� s2 Z PROP. LINE t FOUNDATION _'�j�_AGRICULTURE WELL OTHER WELL PITS/SUMPS r,IN7ENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0f Industrial © Open Bottom r �Manteca Dia."of Well Excavation �[ Dia. of Well Casing { 'Do}nestic/Private Gravel Pack ❑ Tracy' Type of Casing W re'L Specifications" _ Public { Other El Delta Depth of Grout Seal �'�s Type ofzGrout j� © Irrigation IOpprox:Depth _^O-,E�astem�---f-y--Surface Sedl`lnstalled by l Repair Work Done ❑ iType of Pump -��u State Work Done ` Well Destruction ❑ Well Diameter -_ Sealing Material (top 50'1 s Depth Filler Material (Below 501 TYPE OF SEPTIC WORK:i NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within'200 feet_) f Installation will serve: Residence— Commercial_ Other• Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth �t .� SEPTIC TANK ❑ Type/Mfg r ' Capacity ~No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINEr�1 �❑ Nod,&.Length of lines Total length/size 11 FILTER BED "" ❑ Distance to nearest: Well YFoundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL-`-PONDS ❑ ! •�` I herebyrcertify that I have prepared this application and that the work will be done in'accordaince with San Joaquin county ordinances, state laws, arid rules and regulations of the San Joaquin Local Health District. P. Horne-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."Contractors 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." IE The applicant mu al�rafll require "nspe ions. Complete drawing on reverse,side., r t ,� ,jr Signed X Title: �4h�eM 7 dG Date t FOR DEPARTMENT USE ONLY [� Application Accepted by Date i ~� _p ` _ WArea Pit or Grout Inspection by Date Final Inspection by Date_ h Additional Commend ❑ Stk 466-6781 ❑"Lodi -3621 Ll Manteca 823-7104 - ❑ Tracy 83543M 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 CK RECEIVED BY DATE PERMIT"NO. INFO GASH a EH 13-241REV.t 65l O S �- Aw p`ly ` 96' EH 14-26 ``