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APPLICATION FOR PERMIT �. ►�. SAN JOAQUINrLOCAL HEALTH DISTRICTf-f� f P i 1601 E. HAZE t ON AVE., STOCKTON, CA i Telephone 12091 466-6781 ` 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 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 j/� Local Health District. /6 � � J,0 ,,AJ-�l �/��Q ,fob Address_ � City j Lot Size R ea,-.P=< rx PM Owner's Name �C �"1L Address 1 @ -8111C S-! /,,9A to Phone Q - el Contractor h Address i"r (A. f�lj�' k 5 Q- L'7a! ► License No��LJY3a.3_Phone -,4 ^ TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLDL-S� *PROP. LINE 1-9 ..._ 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 i M Public Cl Other I;1 Delta Depth of Grout Seal Approx. Type /Grout . e^e�L I i Irrigation0� prox. Depth I I Eastern Surface Seal Installed by �l YP (Grout Repair Work Done EIType of Pump H.P. 3, State Work pone Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION ( I (No septic system permitted if public sewer is Q -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 �r PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total lengthtsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ 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 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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mut call for all required ' spections. Complete drawing on reverse side. Signed X � ��A�� Title: P Date: _3 R"TIEPAR3MEWTUSE ONLY Application Accepted by t Dater/ Area 52Z Pit or Grout Inspection by �. _.� 7?_�.- D�ye7 L dL Final Inspection by / ' r//' / Date Additional Comments: `^ g,51 pe- _519 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. H zelton Ave., P.O. Box 2009, Stk., CA 45201 a,C �_D.T — ."JQaZ , I V (NFEO AMOUNT DUE AMOUNT RE ITTED CASH RECEIVED BY DATE PERMIT NO. �.EH 13-24(REV.1/85) OS,OD � �� — rf —533 EH 1428