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F APPLICATION FOR PERMIT }t SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA �ze Telephone (209),466-6781 �PERMIT EXPIRES 1 YEAR FROM DATEISSUED ,. .(Com plete.in Triplicatel. tr Application is hereby made to the San Joaquin Local Health District fora sem'°'` �'' permit to construct and/or install the work her91a_d cribQ")This p�rFj'ation is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and�e!?) tions'D#theh�loaquin Local Health District.. i^r h'lAt` '��,T Ta C tt y OF rti:Ov�+ V.$O t a � X 3 �oo� CA �. . . Job Address M C = City Lot Size PM_ n Owner's Name 4- GA I I F &M=j Address _Ito r^�l$ C�.l.cg�� e� Phone Contractor's Name C tc.` �f62 .• license No. ' l�� Phone TYPE OF WELL/PUMP:} _ NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ " "" SYSTEM REPAIR ❑ OTHER ?5K`71M 7- DISTANCE TO NEAREST: SEPTIC TANK _1 O --SEWER LINES, 60 O _ DISPOSAL FLD. — PROP. LINE _2_ FOUNDATION f _ AGRICULTURE WELL�f IahD�OTHER WELL/S`[� PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 4 g Dia. bf.Well Casing ❑ Domestic/Private Cl:Gravel Pack, ❑ Tracy Type of Casing. A)0A7L� Specifications Public-SAw%p&d5S %,OtherTmrrl 9(f ❑ Delta Depth of Grout SealType of Grout ❑ Irrigation 409-!-Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ "" Well Diameter Sealing Material (top 50.1 Depth -�T Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ fNo septic system permitted if public sewer is available within 200 feet.) 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 SEPTIC TANK ❑ '"Type/Mfg I Capacity No. Compartments r ! PKG. TREATMENT PLT. 1:1I Method of Disposal ,. Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No.4 Length of lines Total length/size- FILTER BED ❑ Distance to nearest: Well Foundation Property Line ( SEEPAGE PITS ❑ _Depth i Size" Number SUMPS ❑ Distance to nearest:' •_Well' Foundation Property.Line ay DISPOSAL PONDS El � - Y r - -' C 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. _ 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." •"_ fi1 } The ap t must call for all reguired inspections. Complete drawing on reverse side. F w ps Signed Title: _� yy ��_ Date: �C FOR DEPARTMENT7M OI�IL� �j Application Accepted by ' Data 3 r Area d/ Pit or Grout Inspection by Date Final Inspection by Date G 4 i Additional Comments: 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 4 - ❑ Manteca 823-7104. ❑.Tracy 835- Applicant- Return all copies to: Environmental health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2409,"Stk.r CA 95201 FEE AMOUNT DUE AMOUNT REMiTTEp CK RECEIVED BY DATE n- 9 INFO _CASH+EH 1 3-24 EH 1426(REV.10/83) r