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r „ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 'J 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 i .` PERMIT EXPIRES 1,YEAR FROM DATE ISSUED (Complete in Triplicate) SEP 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 f ul g 3A of the San Joaquin Local Health District. ENVryj[�{K p1s'Vlrt;iV l�fy1�1�C1�r r- €'twfC�fifi�l SERVICCC Job Address7110 E; W City Lot Size q,:5'VPM Owner's Nam"144e,�y� Address a one NAContractorg"/ t ` Address 1 l 16Y'1r i License No.5 .5 Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK t PQ- SEWER LINES /®® DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Ria" of Well Excavatjpn Dia. of Well Casing I KDomestic/Private Gravel Pack ❑ Tracy Type of Casing UY� or Specifications F 1-1 Public f_-1 Other 171Delta Depth of Grout Seal Type of Grout 14 I 1 Irrigation /"Approx. Depth l I Eastern Surface Seal Installed by a mY+ _ Repair Work Done ❑ Type of Pump H.P. State Work Done Weil Destruction ❑ Well Diameter . Sealing Material (top 501 I Depth Filler Material (Below 501 S3 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is i k available within 200 feet.) G Installation will serve: Residence____ Commercial_ Other Number of living units: Number of bedrooms v ' Character of soil to a depth of 3 feet: Water table depth t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No- & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line i 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 Diltrict. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issuedTl sFialt 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 California." The applicant must call for all required inspections. Complete drawing on reverse side" f 9�- r Signed X t Title: 0LV'VLZ.1/ti .T Date: 9f r OR DEPARTMENT USE ONLY Application Accepted by Date / Area 17V Pit or Grout Inspection by Date Final Inspection by � Date _ 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 k INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. F s.EH 13-241REV.1/95) /` EH 14-26 A!, • 'U C7I �— �/ Ri Z