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I I ' APPLICATION FOR PERMIT Z�h^ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Q Telephone (209).466-6781 PERMIT EXPIRES TYEAR 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. F Job Address -2- S® City ~ b Lot .Size PM r Owner's Name S bq�2 Address me Phone r ` Contractor !'I�k r T, �1 Address J �� .License No._3"ASI Phone q7-OVA TYPE OF WELL/PUMP: NEW WELL tR WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION SYSTEM REPAIR F1 OTHER ❑ DISTANCE TO NEAREST: SEPTIC,TANK �-� SEWER LINES DISPOSAL FLD. PROP. LINE �� FOUNDATION ._:.— AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE .TYPE OF WELL PROBLE ",AREA-""CONS-T.AUCTION.SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �p Domestic/Private Md.ravel Pack j ❑ Tracy Type of Casing4� Specifications t (l Public D Other 1 1 Delta Depth of Grout Seal �4_.-120' Type of Grout 1 Irrigation ".0f-Approx. Depth i I Eastern Surface Seal installed by - Repair Work Done ❑ Type of Pump m H.P. 3 ` --_ State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top F i Depth ' Filler Material (Below 50'1 � h TYPE OF SEPTIC WORK: NEW INSTALLATION Is] REPAIR/ADDITION I I ,DESTRUCTION I I (No septic system permitted if public sewer is V available within 200 feet.) Installation will serve: Residence ;Cbrnmercial- — Other Number of living units: Number of bedrooms;-. x Character of soil to a depth of 3 feet:; - Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments , PKG. TREATMENT PLT. ❑ t Method of Disposal Distance to nearest: Well Foundation - Property Line t h Y LEACHING LINE ❑ No. & Length of lines r }� Total length/size i FILTER BED ❑ Distance to nearest: Well I Foundation Property Line f SEEPAGE PITS l I Depth Size Number , i SUMPS L1 Distance to nearest: Well Foundation Property Line f DISPOSAL PONDS ❑ 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, andt t rules and regulations of the San Joaquin Local Health Diltrict. 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." { 9 The apprican a of alt`requi d-inspec o s:-Complete dr g-on revetsi3 side. a -9Z } Signed X ills: 'et� -�r !}�1 Bate: ' F R DEPARTMENT USE ONLY ']tel Application Accepted by Date ■ ! 7- A ea Pit rout nspection by Date o2 inInspection Additional Comments: ✓�♦ 4 #A!t1gV r i ❑ Stk 466-6781 ❑ Wdi 369-3621 Manteca 823-7164 racy 6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2049, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED I CK 11 RECEIVED BY DATE PERMIT'NO. INFO CASH ♦.EH13-24(REV.t i n 5) IWO pAl ��...11l 4 AJ3 17-17?r�� O� 6 `93 Z EH 14-26 1