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b APPLICATION FOR PERMIT 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 /!1 TJ /.y U,7- Ci10___019X7 ty_ Lot Size Owner's Name A ba1y Address f / lrftV da-5%!� /� Phone Contractor's Name C License No. _ �/� Phone TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ED DESTRUCTION F-1PUMP INSTALLATION El SYSTEM.REPAIR (] - 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 O ❑ Industrial El Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications El Public ❑"`Other El 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 C Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below ') j TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) C. Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a dept of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg ,Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance,to nearest: Well 7�0 Foundations Property Line LEA ,HING LINE i ❑ No. & Length of lines /4"Y 15Z . • Pilk Y 6t otal length/size C-52 A'> S4� r FILTER BED ` Distance to;nearest:. 701 --Foundation� Property Line SEEPAGE PITS ❑ Depth ize Number SUMPS f ❑ 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 must callZfr;qA;spections. Complete drawing on reverse side. 7 /Signed X i Title: dc,��tt�s�� Date: 3 �U FOR DEPARRAENT USE ONLY `r Application Accepted by Date (JT Area Pit or Grout Inspection b Date Final Inspection/by — Date Additional Comments: V ❑ Stk 466-6781 ❑Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy' 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2099, Stk., CA 95201FEE _ INFO AMOUNT DUE AMOUNT REMITTED CASH -RECEIVED BY DATE PERMIT`'NO. + EH 1124(REV.10/83) EH 14-28 's