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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 _! S 2 S /��1?-�.V G _ City �a b�� Lot Size 'L PM Owner's Name ' "+ IJP W, Address c�APhone 3. o /� ,,— i� Contractor qaS.Address 00. Y�., 1 � License No Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION,9 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO)NEAREST: SEPTIC TANK S SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS x ❑ Industrial ° ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ! Z Dia. of Well Casing }� Domestic/Private $;Gravel Pack ❑ Tracy Type of Casing Specifications i ❑ Public ❑ Other ❑ Delta Depth of Grout Seal J t50 Type of GroutCj- t ❑.Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by CLIIl.T12�7d 12 Repair Work Done ❑ Type of Pump ,Cu154 H.P. f State Work Done AWN 4-K Well Destruction ❑ Well piameter —Sealing Material (top 50') �J Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW-INSTAWkTION-0 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r -_ available within 200 feet.) ( n Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms F r; Character of soil to a depth of 3 feet: Water table depth { , l.- 1 w �/v 1 SEPTIC TANK ElType/Mfg � _ Capacity No. Compartments PKG. TREATMENT PLT. ❑ _ S} Method of Disposal r �j Distance',to nearest: '�'Well .Foundation' Property Line LEACHING LINE ❑ No. & Length of lines s t Total length/size FILTER BED ❑ Distance to nearest: Wel! "jFdundation Property Line SEEPAGE PITS ❑ Depth Size �j Number ttf SUMPS ❑ Distance`lto..nearest:._WeA -_Foundation_ Property Line ! DISPOSAL PONDS ❑"; N I hereby certify that I have prepared this application and that the work will be done in abcordance with San Joaquin county ordinances, state laws, and rules and regulations of the Sa Joaquin Local Health District. . _ �; a j I Home owner or licensed agen't's°signature certifies the following: "lcertify that in the-performance of the work for which this permit is issued, Ilshall not employ any person in such manner as to become subject to workman's compensation.lavl s 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 cdmpensa- tion laws of California." y The applicant must call for all re it d inspections. Complete drawing-on-revers`e side.W,` Signed X , "4�/lJ1R. Title:071� Date: k: DEPARTMENT-USE ONLY r Application Accepted by Date Area 2 f c., \ � � Date ? C? Pit or Grout nspection by� L Data �� 7 -C7 E� Final Inspection by_ ` o i i a Additional Comments: G�l+ e`a#c--E-8 r — C `[l Gr--: 3-k—5 iz... rs 2) ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant- Return all copies to: Envoironmental_Health-PermitbServices•T6DT E.'Hazelton Ave:;•-P.O..Box 2009, Stk., CA.95201--- INFO AMOUNT DUE } A/MOUNT REMITTED GASH RECEIVED BY DATE PERMIT NO. + EH13-24(REV.I/95} /Q�/DQ /` C/� (}� ••.. i EH 14-28 T q o- `i f-7 I_.