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912- APPLICATION FOR PERMIT Cate v=r SAN JOAQUIN LOCAL HEALTH DISTRICT a s -/-v C, 1601 E. HAZELTON AVE., STOCKTON, CAurl� r•, Telephone (209) 466-6781 441/r 1II PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � x,41 (Complete in Triplicate) AUG l9 Q Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work" in described. This IT ation is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules � o s of the San Joaquin Local Health District. p��j� rV� qEA�TN C� Job Address G1 City Lot Size�� ,�(eS PM Owner's Name ._474w Q,d/ Address 154d.,E Phone "_, e Contractor V 6 icense No. Phone M2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT �4_ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD,33nff–PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private �Z Gravel Pack 'JA-Tracy Type of Casing /flllC /rO Specifications Fi Public F-1 Other 1-1 Delta Depth of Grout Seal LMJffE4_ftyr Type of Grout I I Irrigation _ .Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done 17 Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) 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 L1 No- & Length of lines Total length/size FILTER BED 0 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 ❑ - – - 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 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(tiring 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 applica us all or all r uired inspections. Complete drawingon r erse slid Signed X Title' Date: F DEPARTMENT USE ONLY Application Accepted by Date �r Area Pit or Grout Inspection b Date Final Insp ction by ea Date Z2 Additional Comments: I [.G ❑ Stk 466-6761 ❑ ❑ Manteca 3-7104 ❑ Tracy 835 6385 Applicant- Return all copies to: Environmental Health Per ern eon ve. P.O. Box 2009, Stk., CA 95201 /,r37 a -s d IFEE NFO AMOUNT DUE J AMOUNT REMITT(ED / CCK f-ASH // RECEIVED BY O _DATE PERMIT NO. a EH 13-24 IREV.1/9 51 —;b-00G -17— EH 1428