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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Fit f . 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209) 466-6781 �t./ PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) TSL r-LfVA Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the �, �application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wel!lpump and the vu"11,n,".5 oche San Joaquin Local Health District. ,lob Address �� 'ii 1 �� City Lot Size PM -74 Owner's Name — "y - Address Phone 431. Contractor U 11 itJl} Address 1 W O License No.V2,ff Phone_ TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ��il1�YSTEM REPRIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' FOUNDATION- AGRICULTURE WELL. _ OTHER WELLPITS/SUMPS' y INTENDED USE T ',PE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing Domestic/Private Cl Gavel Pack 1-5Tracy Type of Casing Specifications ' Type of Grout I ❑ Public - Ot`her ❑ Delta Depth of Grout Seal YP t l I i Irrigation �YApprox. Depth��i I�Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump _JZLE�.1 H.P. �L State Work Done C Well Destruction ❑ Well Diameter Sealing Material Itop 501 IIRiler-Material Melow 50'1 —�_w---, v ,..�..�.- TYPE OF SEPTIC WORK: NEW INSTALLATION I.] nr-PAIR/ADDITION I I DESTRUCTION I I JNo septic system permitted if public sewer is available within 200 feet.) y installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms f 3 feet: Water table depth Character of soil to a depth o it C SEPTIC TANK © Type/Mfg ' Capacity_ No. Compartments - + PKG. TREATMENT PLT. CJ Method of Disposal Distance to nearest: Well Foundation Property-Line t "r t + Total length/size LEACHING LINE ❑ No. & Length of lines1 FILTER BED ❑ Distance to_nearest: Well Foundation ' Property Line , SEEPAGE PETS ! I depth Size Number ' SUMPS c Ll Dlstarice to nearest V."'Well Foundation Property Line �- -_- .�- 'DISPOSAL PONDS " 0'4�� -•_ . �'- _ �.y,-w--- _•--•�`*wk -- - i I hereby certify that f have prepared this application and tFiat 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 agents 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,t shall employ persons subject to workman's compensa- tion laws of-California. The applicanta all squire Complete drawing on raver ode. Signed X ills: Date: IN FUR DEPARTMENT USE ONLY Application Accepted by __..ti. Date. ( Area r . a-lZy SSs Pit or Grout Inspectio b Date Final Inspection by Data Additional Comments: _ ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 EJ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95241 FEE AMOUNT DUE AMOUNT REM TTED CASH RECEIVED 9Y DATE PERMIT NO. ` INFO +.EH13-241REV.1/85f + EH 14-26