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i APPLICATION;FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r1601 E. HAZELTON AVE., STOCKTON, CA -Telephone (209) 466-67$1 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r ; ialOrr'r :(Complete in Triplicate) i Application is he4eby 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. " -- - , n a Job Atldress � City /1'Aticlnf _Lot Size �ai- kPM 3 ff _ )) _ Owner's Name '` 4«tot�� P.- O eer ' `Address 3S/ ic,..t� et f�ci -..'Phone Z^ 17 Z� ContractorAddress License No. -a f Y� Phone q TYPE'OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El' C' + " PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f{,: DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. EINE p FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F1Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation___w__._ Dia. of Well Casing 111 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public f ❑ Other ❑ Delta Depth of Grout Seal } Type-of Grout ❑ Irrigation --Approx. Depth E1 Eastern Surface Seal Installed by--.. Ji,RepairlWork Done ❑ Type of Pump H.P. State Work Done Well Destruction O Well DiameterSealing Material atop 50'1Depth Filler Material {Below 50')r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION iNoseptic system permitted if public sew ' I v available within 200 feet.) Installation will serve: Residence_ Gommercial i✓ Other_'�� i t Number of living units:� Number of bedrooms Char acter of soil to a depth of 3 feet: Water table depth ` SEPTIC TANK X Type/Mfg Capacity NSIM No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal r distance to nearest: Well Foundation Property Line ' LEACHING LINE No. & Length of line : Total length/size Cpo ' FILTER,BED "� 11Distance to nearest: Weil Foundation Property Line SEEPAiGE PITS ❑ Depth Size Number + SUMPS + D Distance to nearest: Well Foundation Property Line y DISPOSAL PONDS ❑ r. 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 t 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 signatuW= certifies the followin I certify that in the rformance of the work for which this permit is issued,I shall employ 9�" Pe p p y persons subject to workman's compensa- tion laws of California." The:ppl,can s all for all requir in ctions. Complete drawing on reverse side. Signd Title: - - t Date: ,�2 FOR DEPARTMENT USE ONLY 4 f Applic tion Accepted by Ct:n� ate r./' Date "Z "�1� Area a f j° 4 t R Inspection /g-,Pit or Grout Inspection by Date Final'inspection 6y Date I .' Additional Comments: � I K'Stk� 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 . ❑ Tracy 835-6385 4 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0. -+ E11 13-241REV.I/95) EH 14-26 1 y 1