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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 � PERMIT EXPIRES'1 YEAR FROM DATE ISSUED" ,.n. I (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 Ryles and Regulations of the San Joaquin Local Health District. o Job Addresses .1 ��. (11 ^ . - City ^6t Size `•` PM ' (Owners Name Phone Contractor I c"/a C JAII Address t,-PX 03 J?2)94 License N w Phone TYPE OF WELL/PUMP: fNEW WELL ElWELL REPLACEMENT ❑ DESTRUCTION ❑ e PUMP INSTArLLATION ❑ i �. SYSTEM REPAIR.. OTHER 11 DISTANCE TO NEAREST: SEPTIC TANK SEWER'LINES_' �J `' DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL z PITS/SUMPS INTENDED USE o TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open4_Botfoin--...,,,,,,❑ Manteca Dia. of Well Excavation i Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing / Specifications ❑ Public ❑ Other 1 ❑ Delta Depth of Grout Seal i Type of Grout ❑ Irrigation ----Approx. Depth ❑ Eastern S ace Seal Installed by# Repair Work Done X Type of Pump,, H.P. State Work Dome_ U-( <` Well Destruction ❑ Well Diameter) Sealing Material (top 50') (� Depth '° Filler Material (Below 501 o i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) p(: Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil.•to a:depth-of 3 feet: z f '- + � _` �- Water table depth SEPTIC TANK t ❑, Type/Mfg- Y9 ; }. '� {Capacity No. Compartments PKG:TREATMENT P.LT`O 't'�; 3+ "` Method of Disposal, s t. .A, Distance,to nearest:1AWell ' .. t- `- i Found tion ? Property Line LEACHING LINE ❑ No. & Length of lines Total length/size j FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS ❑ Depth Size, Number SUMPS ❑ 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 j rules and regulations of the San Joaquin Local Health District. _Home,owner or licensed:agent's signature-certifies-the-following:°"-certify that<in.the,performance.of.-the-wot'k for which thispermitiss 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,1 shall employ persons subject to workman's compensa- tion laws of California.; y"=�d)Aspec sA , J The applican mu t call" r all rComplete drawing on . verse side. Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date � Area Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ 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 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIIT'NO. + EH13-24(REV.7/85) �C� .Q� dry .: /C ��[Q�Gt '•�bt7 'i EH 14.26 J Ob - t i