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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT p Ay M ENS', 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781Ir I . PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Q�� 98� (Complete in Triplicate) N-MENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work he made in compliance with San Joaquin County Ordinariffi6n is rdi�lldbs � �f� d Rl ce No.549 for sewage or No. 1862 for well/pump and the Rules andSan Joaquin Local Health District. Xf r Job Addressr•iLl�a:1�..�aa� .5 L /llfll r !� City ' Lot Size 46CCek" 1 PM Owner's Name air Address S j - 11 t f 7 ry 90 ' Phone p Contractor Q Address License No. Phone TYPE OF WELL/PUMP: i ;"j� NEIN WELL ;9 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMPI INSTALLATION El. SYSTEM REPAIR El OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ,/11-6 / SEWER LINES DISPOSAL FLD./W PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS. INTENDED USE TYPi OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fi ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �Q Domestic/Private Gravel Pack ❑ Tracy Type of Casin 9 Specifications ❑ Public ❑ Othh r ❑ Delta Depth of Grout Seal T ro t Type o LJ!irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by f G . Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 ` Depth IM Filler Material {Below 501 /? �. TYPE OF SEPTIC WORK: NEW.�INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic sy4tern permitted if public seyWIMP available within 200 feet./ In Installation will serve: "Residence_ Commercial_ Other Number of living units: I� Number of bedrooms T f y~ Character of soil to a depth of 3 feet: p Water table depth SEPTIC TANK e ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well Foundation Property Line ! f LEACHING LINE ❑ ;,,,No'l& Length of lines Total length/size FILTER BED 17 .`bis ,Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 'DISPOSAL'PONDS - .❑ Ali . . f a f. - — - 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 Ca'fornia." The app/' ant ust call for all reglui inspections. Complete drawing on reverse side h Signed Title: Date: /n /.2 it FOR EPART ENT USE ONLY Application Accepted by p Date ®�0��+ Area Pit or Grout Inspection by Date ' %Z v !Final inspection by Date Additional Comments: IM ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 Applicant- Return all copies to: Environmental Health Permit/Service's 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEEW,, A INF MOUNT REMITTED RECEIVED BY DATE PERM7T'NO. LAW EH 14-26 + EH 13-Z4 1REV.t/as) r�ry�3 `7o \ � f� 7 k