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I I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT k Z. 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 T PERMIT EXPIRES 1'YEAR FROM DATE ISSUED 4 (Complete in Triplicate) C 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 Counry Ordinance No. 549 for sewage or No. 1862 for welupump and the Rules and Regulations of the San Joaquin Local Health District. Job Address A � � City 0 Lot Size PM Owner's Name -_ �� _..-i�zrm Pah Address ISM / k Xluhe Q idW )7 PKbri� �77 Contractor Jr Address �S R-1agAte, 199- License No. Phone TYPE OF WELL/PUMP: V NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION F-1 SYSTEM REPAIR 11 OTHER ElI � DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES DISPOSAL FLO. 140 PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL ,Zn s PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ OpenBottom D Manteca Dia. of Well Excavation Dia. of Well Casing VDomestic/Private 'AGrave! Pack ❑ Tracy Type of Casing l Specifications /� ! M Public F1 Other n Delta Depth of Grout Seal Typo of Grout I I Irrigation --.Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW LNSTALLATION I I REPAIR/ADDITION I I DESTRUCTION [ I (No septic system permitted if public sewer is ( f` available within 200 feet.) V }I 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 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 applic ust call for all req d inspections. omplete drawing reverse si Signed X Title:riaENT L Date: -4�'90 FO DEP USE ONLY Application Accepted by Date l �_L��y, Area----- �..._. Pit or Grout Inspection by Date inal Inspection by Date ZSR Additional Comments: No 4 ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant -,Return at] copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 -3 25'.� C :—FEE a1 . INFO AMOUNT DUE AMOUNT EMITT GASH RECEIVEDAY DATE PERMIT'NO. ..EH1 -21(REV.iiNS) EH 194-2e li