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APPLICATION FOR PERMIT V\� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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. Job Address J C ' zr)Qr � r City ESCA/0 Y) Lot Size 114 PM J �A A �I��- #7717- t2d G� off' oak"a/,p Owner's Name �Z Addresshone Q Contractor's Name©/,)Oh�i9C>C r1�7 t . License No. L-:?g(-aPhone _), ) 9 3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 11 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 Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ 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 TYPE OF SEPTIC WORK: NEW INSTAL-LATION —'REPAIR/ADDITION 9 DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence L Commercial_ Other Number of living units: / Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK X Type/Mfg WE-CAST C PAY 40— Capacity .Z U O c/A� No. Compartments PKG. TREATMENT PLT. ❑ Method ofDDii' te� sp sal •- Distance to nearest: Well dt+ Foundation t7'4- Property Line �ry LEACHING LINE 1K No. & Length of lines 2" yb' ke ct,k 4.'i NTS Total length/size O 1 FILTER BED ❑ Distance to nearest: Well �� Foundation / . Property Line 420 t SEEPAGE PITS ❑ Depth Size umber SUMPS A( Distance to nearest: Well/ a1� Foundation �f_ Property Line DISPOSAL PONDS ❑ 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 mus cal for allrequired inspections. Complete drawing on reverse side. Signed X e `/_ Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by t 11 Date_�1,�a � Area CIL;' itst—J—C Pit or Grout Inspection Date Final Inspection by Date Additional Comment . r� d i G ElStk 466-6781 i -7104 El Tracy 835-6385T 4F 77 � ��v� IV c w�tt Applicant- Return all copies to: Environmental ealth Permit/Services 1601 E. Haze ton v ., A 95201 ✓ FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH 3L� ` f + EH 13.24(REV.10/83) '70 _ 1/ EH 14.28