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k. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address' i�3 y8 D f b'f S I C,/V r7 G(. City AtliTed�b Lot Size PM t Owner's Name %TvhN Do Address 3 y$ Pkv i 2' &W Al Phone ffx3,4;6&_Jd Contractor aN Address f»c7c'c r rjC� License No.Wr S1��Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL WEPLACEMENT.❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL Y `"OTHER WELL - .PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom El Manteca � Dia.-of Well Excavation Dia. of Well Casing Ll Domestic/Private ❑ Gravel Pack 'D Tracy "Type of Casing Specifications a 1`1 Public L-1 Other ❑ Delta Depth of Grout Seal Type of Grout 04 1 1 Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. - State Work Dane Well Destruction ❑ Well Diameter Sealing Material.(top 50') {C, Depth Filler Material (Below 50'1 —_ G TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I,IM DESTRUCTION { I (No septic system permitted if public sewer is �- - available within 200 feet.k Installation will serve: Residence_ Commercial_ Other fFPpG�4 C+/�fN Number of living units: I Number of bedrooms Character of soil to a depth of 3 feet: /+l&/a7` � Water table depth SEPTIC.TANK H Type/Mfg P7^e? C/15 T Capacity ! 'JOD --i No. Compartments .� PKG. TREATMENT PLT. ❑ Method of Disposal yy ��O ' I .� Distance to neatest: Well y0 f Foundation I D r f Prop ert Line r LEACHING LENE ,V No. & Length of lines foo r "-TofaLlerigthlsize olp0� FILTER BED ❑ Distance to nearest: Wel! 7eY Foundation ,f .5- ` Property Line i 1 t I SEEPAGE PITS 11 Depth Size — -- - Number SUMPS ❑ Distance to nearest: Well Foundation .. Property Line DISPOSAL PONDS ❑ fi 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 Di§trict. Home owner or licensed agent's signature certifies the following: "I certify that iri 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 mu call for all required inspections. Complete drawing on reverse side. f Signed X Title: Date: Fp0biPA1RTk4NT USE ONLY Application Accepted by Date Area r 1 Pit or Grout Inspection by ' A Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED �C K RECEIVED BY f.1 DATE PfERM17''NO. ^°r ..EH114-2d !13-24(REV.1/95) EH U—� e . � r!~VO I