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APPLICATION FOR PERMIT SAN JOAQUIN' LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVL, STOCKTON, CA {,�(\y,, Telephone (209)'466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) . p; 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 2/ 6A1-0AJAet9 4A/ City 5 A) Lot,Size .� PM Owner's Name Address Phone Contractor's Name AFL YD 0 9 l� 0 03A License'No. r +��Y7 Phone 6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' j DISTANCE TO NEAREST: ,SEPTIC TANK SEWER LINES DISPOSAL FLD. X14^ J(PROP..LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS%SUMPS r INTENDED USE �;TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , ❑ Industrial O Open Bottom El Manteca Dia. of Well Excavation w Dia of WeIL Casing 11 Domestic/Private ElGravel Pack ❑ Tracy Type of Casing Specifications { ` ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ; Type of.Grout� s ❑ Irrigation I!--Approx. Depth ❑ Eastern Surface Seal Installed by `'#-•+i � 4 s Repair Work Done ❑ Type of Pump H.P. State Work Done !� Z1;11 Well Destruction ❑ Well Diameter Sealing Material (top 501 ` Depth Filler Material (Below 501 .r TYPE OF SEPTIC WORK: NEW MISTALLATION V REPAIR/ADDITION❑—DESTAUCT104❑ (No septic system permitted if public sewer is available"within 200 fek.)4 r1�r Installation will serve: Residence" Commercial_ Other living� Number of 3.f g units:� Number of bedrooms — ,, � � � Character of soil to a dept f 3 feet: L/Q "! ti"1� s�� Water table depth SEPTIC TANK w e Type/Mfg �� -.4 Gapac'ity /3.(� No.%Compartments Ir .L PKG. TREATMENT PLT. ❑1 ` )} Method of Disposal Distance to nearest: Well "Foundation_ —'Property Line # ' � 1 LEACHING LINE No. & Length of lines gs _ �' Total length/size FILTER BED ❑ Distance to nearest: Well Foundations Property Line° ^» SEEPAGE•PITS-- Depth-----•f�- J =_Size rr 3` Number % � � r SUMPS El Distance to nearest: Well a s Foundation 000 Property,Line J 410 DISPOSAL PONDS ❑ '4*= I hereby certify that I have prepared this application and that the work will be done in accordance4ith 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 vvFich this permit srsued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawl n�g on reverse side. Signed X Title: 9.4,& Date: FOR DEPARTMENT USE ONLY c Application Accepted by # ? Date ✓� Area fff �, Pit or Grout Inspection by 4. Date inal Inspection by Date I Additional Comments: - f I Stk 466-6781 ❑ Lodi 369-3621- ❑ Manteca 823-7104 ❑ Trac. 835-6385 I App cant- 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 CASH CK RECEIVED BY DATE PERMIT"NO. +EH 13-24(REV.10/83) I � �� .. .IJ 13 73-5- . EH 14-28 1