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APPLICATION FOR PERMIT . - ` SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZEL—I ON AVE., STOCKTON, CA n! Telephone {209} 466-6781 j PERMIT EXPIRES 1 YEAR FROM DATE ISSUED –r4t4 (Complete in Triplicate) l�+`I ON�� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This al ication 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 'Y3 "`�(�61 GI �o City �C / Lot Size PM I Owner's Name �S, Address �u3 .Q�. . /- f,0,/, � 9 413J r/S''7 Phone Contractor Address ` TYPE OF WELL/PUMP: License No. Phone NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR-❑ --OTHER, ❑ DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL i PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 15 Open Bottom ❑ Manteca Dia. of Well Excavation El Domestic/Private 11Gravel Pack ❑ Tracy T Dia. of Well Casing ype of Casing Specifications V ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ❑ Irrigation -A Type of Grout ---Approx. Depth ❑ Eastern Surface Seal Installed by.� Repair Work Done ❑ Type of Pump H.P. V ' Well Destruction ❑ Well DiameterState Work Done Sealing Material (top 501) t... �F Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No se tics stem, ' s P Y permitted if public sewer is Installation will serve: Residence— Commercial_ Other ailable within 200 feet.) I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: d SEPTIC TANKWater table,depih ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ p Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines , Tota! length/size FILTER BED ❑ Distance to nearest: Well Foundation # Property Line SEEPAGE PITS ❑ Depth Size i } Number SUMPS ❑ Distance to nearest: Well Fouriaa o-n .= y"""-Propertj - . _t DISPOSAL PONDS Cl Line 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 r 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 tion laws of California." permit is issued,f shall employ persons subject to workman's compensa The applicant call for I r quired ins tions. Complete drawing on reverse side. Signed '�� al.�t/1�} Title: - u - Date: 3 FRR DEPARTMENT US�ONLY ' Application Accepted.by _ - _ `1 I ��. � J�+..+n(l��.l� Date- i . Area �� Pit or Grout Inspection by Date Final Inspection by a Date Additional Comments.- 0 omments;❑ Stk 466f781 ❑ Lodi 389 3621 : ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 1 FEE AMOUNT DUE AMOUNT REMITTED CK INFO RECENED BY DATE PERMIT N0. +EH 13.24(REV.4/85} i EH 14-28B.5, �:Z /S ... 'i�-7^ 2I