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APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE TON AVE., STOCKTON, CA 'Telephone (209) 466-6781 It% ell, PERMIT EXPIRES 1 YEAR 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 deiGribed.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 Distri-ct-. Job Address L5/6 City _Lot Size PM Owner's Name /if I -14) 370 kA20ddress Phone I Contracto Address License No h ne rA k�&0_1_�Q �2 � / ell A1,24 14 0 TYPE'OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION n PUMP INSTALLATION 0 -SYSTEM REPAIR F] OTHER El 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 El Industrial.- % 0 Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications 1:1 Public E Other 0 Delta Depth of Grout Seal Type of Grout [D Irrigation k ---Approx. Depth El Eastern Surface Seal Installed by Repair Work Done D Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material Itop 501 Depth Filler Material iBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION LJ DESTRUCTION)?r(No septic system permitted if public sewer is J available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units:— Number of'bedr-- Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Ty pe/Mfg Capacity— No. Compartments PKG, TREATMENT PLT. El Method of Disposal Distance o nearest: Well Foundation Property Line LEACHING LINE 0 No. & Lengthol"lines Totlkler�qtW/iize- FILTER BED F-1 Distance to nearest: -Well Foundation— Property Line -41 SEEPAGE PITS 11 Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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. 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 perf6rmance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicamu 11 f all requ' inspections. Complete drawing on regerse sidef Signed X Title--- <!Ja�t t Dat Application Accepted by A-t,?'W A__4 FOR DEPARTMENT USE ONLY Date Area 2— Pit or Grout Inspection by 41Z Date Final Inspection by I.C_7 - - _ Da te Additional Comments: C1 Stk 466-6781 0 Lodi UM-3621 [I Manteca823-7104 j 11 Tracy 835-&%5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O..Box 2009,' Stk., CA 95201 4 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO + EH3-24 REV 00 EH 114 28 AV rad -1r-87 1172,