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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED f (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. 1662 for wail/pump and the Rules and Regulations of the San Joaquin Local Health District. / S/r87-0pyalL�ey �G! City�rG�,W/) C-l�M t Size /oAer�s P Job Address p Owner's Name ' � 4V1X.4 Address AW1� � � �� 6f Phone Contractor ;r,40 � Address+04-44 License No.'VyVS91 P h a n e TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE l FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ` FI Public Cl Other f 1 Delta Depth of Grout Seal Type of Grout _ I I Irrigation —_-Approx• Depth l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. - 'State Work Done Well Destruction F1Well Diameter Sealing Material (top 50') Depth Filler Material l6elow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITIONA DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other ther Number of living units: 1 Number of bedrooms ° f Character of soil to a depth of 3 feet: /V1_1a Water table depth SEPTIC TANK X Type/Mfg a ess7 /1� - Capacity /64o No. Compartments Z PKG. TREATMENT PLT. Cl _ Method of Disposal Distance to nearest: Well $B Foundation _ a r Property Line I LEACHING LINE jar No. & Length of lines x SO Total length/size r ads� FILTER BED ❑ Distance to nearest: Wel{ Foundation Property Line 1. SEEPAGE PITS I I Depth � Size Number A. SUMPS ,Pfj Distance to nearest: Well 'p z f=oundation y� Property Line 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, and rules and regulations of the San Joaquin Local Health District., .:N,-� Horne 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant mus call for all required inspections. Complete drawing on reverse side. Signed X Title: v ""'" - Date: a �Q67 FOR)DEPARTMENT USE ONLY _ Application Accepted by ; " Da "' Ares Pit or Grout inspection by bate Final Inspection byDate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO +.EH i3-24 Iii EV.rin5) ri � '� /•ZO 0 O "3LI EH 14 26 J