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APPLICATION FOR PERMIT 'f kP SAN JOAQUIN LOCAL HEALTH DISTRICT , u 1601 E. HAZEL T ON AVE., STOCKTON, CA 0E Telephone (209) 466-6781 A114 JQ 4QtJ 1992 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED EN.y. o ,�� E�_Tf1O 7V7Y n l`iVE,1g7 SERVICES (Complete in Triplicate) :� i ��HEIr TN+JIVlSllt7 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 Regylations of the San Joaquin Local Health District. '""" Job Address Me,0 b A A'ib &'t 01 CitA000 RAID Lot Size t PM p Owner's Name CC y15 Ilk)A-1 F p?S;�-Address 13 In 3 Phone; `b ! Contractor f^.� Address ^1 C �Il �SEL License No. ;�? Phone�� /`3,9 TYPE OF WELqTUM NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r-'FOUNQATION ` ---=A'GRIC-UL-T-URE-WEL-L-=� L_OTHER=WELL= -.Pt-T5/SUMPS= INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I� l O Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ID Gravel Pack El Tracy Type of Casing Specifications �* (fd Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout - !I I I Irrigation -Approx. Deep`th, I 1 Eastern Surface Seal:installed by p LI Repair-Work-Done � Type of Pump ,_] �-� H.P. �� State Work Die�L�p��G� UI �1 Y6 Well Destruction ❑ Well Diameter Sealing.Material Itop 501 316 6mg_� Depth s � Filler Material (Below 50-') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t I DESTRUCTION I 1 (No septic system permit ied if public sewer is 1/,q�y1 - f available within 203 feet.) 1 h installation will serve: Residence_ Commercial_ Other h -- Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 7 _-Type/Mfg - Capacity � No. Compartments' N 1 PKG. TREATMENT PLT. ❑ �. w " ' " Method of Disposal Distance to nearest: Well Foundation Property.Line IM LEACHING LINE Cl No. & Length of lines _ Total length/size IM FILTER BED ❑ Distance to nearest: Well FoundationProperty Line � < IM SEEPAGE PITS 1 1 Depth Size i3 Number IM SUMPS Ll Distance to nearest: Well Foundation Property Line. DISPO5At--POiVDS`,t�`=r❑, f 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." , The applicant must call for all required inspections. Complete drawing on reverse side. l Signed Title: `� Date: i FOR DEPARTMENT USE ONLY _ Application Accepted by Date �2 qZ- Area Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: II ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2019, Stk., CA 9520 FEE INFO AMOUNT DUE AMOUNT REMITTED Cx RECEIVED BY DATE PERMIT'NO. ♦.ER13-24 IREY.�/n 51 EH Fill IM