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APPLICATION FOR PERMIT rs ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE TON�AVE., STOCKTON, CA "ECEIVE"D Telephone (209) 466-6781 DEC 6 49$9 u PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIR�;1�'OMIENTAL HEALTH (Complete in Triplicate) pE6�ib11''/C�' ��/s , Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein dlescT(ffe��lAiis%lication 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. y� / Job Address —I Y /.�Q ( 0V W 14 /A N u City S4" t Size PM Owner's Name ( Address 1.1 IK2 / JllG1 L iJi Phone Address License No. 3?3 Phone V1466-q6 T Contractor I TYPE OF WCL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM'REPAIR [&/ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1. 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 °-O„Tracy Type of Casing Specifications I'1 Public ❑ Other Gl Delta IN Depth of Grout Seal Type of Grout .. I I Irrigation .Approx. Depth �fa'I 3r_n? ��` ace Seal Installed by - DWTR �^1 Repair Work Done Type of PumpDWT.' * // State Work Done Well Destruction ❑ Well Diameter Sealing Material (top,A') /Depth Filler Material (Below 501 -- TYPE OF SEPTIC,WORK: NEW INSTALLATION I REPAIR/ADDITIONTl -DESTRUCTION I I (No septic system permitted if public sewer is .; t a• �+i available within 200 feet.) Installation will serve: Residence_ Commercial— Other y N Number of living units: Number of bedrobnls'+f 1 >"a U, Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg ✓"' Capacity No. Compartments PKG. TREATMENT PLT. ❑ .1 Method of Disposal Distance to nearest 1 WellI Foundation Property Line �QJ 1� � � R 60 LEACHING LINE ❑ No. & Length of,Ijnes . _i X Total length/size NFILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Ii 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 rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the followin`d,"I certify that in the performance of the work for which this permit is issued, I shall not employ any per anner as to become subject to woIr man's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the fol wing: ify that in th orm c of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of arfornia." The appli nt mus c o all re i ete drawing on e e s) Signed X Title7. :' Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 1.77 Area Pit or Grout Inspection by Date i Final Inspection by G} Date Z Additional"Comments: ❑ Stk-466-6781 ❑ Lodi 369-3621 ❑ Manteca `823-7104 �❑ Tracy`7835-6385 ., Applicant - Return all copies to: Environmental Health Permit/Services 1601 E�,Hazelton Ave.,'P.O.'Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH +.EH 13-24(REV.1/H 5) EH 14-26 i