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luAPPLICATION,.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 'j 6 1987 I PERMIT EXPIRES 7 YEAR FROM DATE ISSUED I=NV[RCMElVTAL HEALTH 3ni„ (Complete in Triplicate? FERMIT/SERVICES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereE in 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 aa•D,_ S mea [ ,, "fir A a_ City Lot Size PM Owner's Name Address" w Phone i b Contractor, _. Address . License Na.7�cJ�6Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELc.L REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑- OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES:. DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS—_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation a Dia. of Well Casing Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx..Depth ❑ 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 501 N TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (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:A A s _ Water table depth k SEPTIC TANK ElType/Mfg Capacity "'" rr= No. Compartments I PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: ,Well Foundation - Property Line LEACHING LINE ❑ No. & Length of lines '. "r T r l--length/size FILTER.BED El Distance to nearest: Well Foundation W I y4"Property Line 1 'r 1 SEEPAGE PITS ❑ Depth Size Number ' i SUMPS. Q., Distance to nearest:" a Well Foundation Property Line DISPOSAL PONDS Li - _ I hereby certify that I have prepared-this-application-and-that the-work-will-be done-in-accordance-with-San-Joaquincounty ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. - - ti Home owner or licensed agent's signature certifies the following: "I certify that in the petformance,ofihe work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman:s compensatior')aws of CalifoFnie::''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 sh-all employ persons subject to workman's compensa tion laws of California." The applicant esT"c II for all required inspections. Complete drawing on reverse side. Signed Title: A111 -. - Date:46/ "6� FOR DEPARTMENT USE ONLY 4 1 Application Accepted by Date U —D Are f Pit or Grout Inspection by n Date Final Inspection by Date -�=� Additional Comments: ' 1 ❑ Stk 466-6781 ID Lodi 369-3621 ❑.Manteca 823-7104 ❑ Tracy 835-6385 a Applicant- Return all copies"to: Environmental Health.Permit/Services 1601 E. Hazelton Ave.,-P.O. Box 2009, Stk., CA 95201 FEE x INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV,I Rbl G �Q } - ;. 11// 1, � r EH 14-ZB j- �J l IeV —"1I50