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APPLICATION FOR PERMIT a x SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE1ON AVE., STOCKTON, CA Telephone (209) 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 Local Health District. •y ,:, I �� _01 Job AddressQ� 'r�+ T..� ��'1 O � -. City i i Lot Size 15Dx PM C4+A�l '::;S R STA-)_ CREAMS Z kl (9t 6) �� X1/1 Owner's Name �"NT� �� " CO- Address �0�✓ �� 4Phone Contractor CON' �'� Address V License No. Z Phone 3 2- 3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Od' M001TOP�JEi k DISTANCE TO NEAREST. SEPTIC TANK M SEINER LINES DISPOSAL FLD. PROP. LINE FOUNDATION J 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 EI Gravel Pack ❑ Tracy .Type of Casing= �Vr�- Speccations ❑ Public Fr/0 pr {�D N. ❑ Delta Depth of Grout Seal Type of Grout t ❑ Irrigation �I i_Approx. Depth ❑ Eastern Surface S. Etta eal Installed by PL I Repair Work Done E3 Type of Pump H.P. State Work Done M Well Destruction ❑ Well Diameter' Sealing Material (top 50') JAOH I-TVP,1 N<4 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 et.) Installation will serve: Residence— Commercial— Other Number of living.units: Number of bedrooms :: Character of soil to a depth of 3 feet: depth SEPTIC TANK .J Type/Mfg ._ Capacity No. Compartments f PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C7 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line f SEEPAGE PITS ❑ Depth K Size Number -SUMPS- " - - -LJ 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 fallowing: "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 must call for�equir inspections.-Complete drawing on reverse side. Signed x Title: OWNER Data: 10-22-86 =DERT �OSIEONLY EI Application Accepted b Date —�+� a— Pit or Grout Inspe io y bate Final Inspection by Date i Additional Comments: ❑ Stk 466-6781 El Lodi 369-3621 El 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 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + Ek 73-21 IREV.v a 5) D� S. ato3t C � l��v/�t4 b-t36� EH 1428