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TJD APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 Cl PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) t., -r 0 /-- Re_C�Aw 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. elt__ "'tom Job Address ��f� City �� r©i r cl 7 Z /i //�l�/�V/ Lot�►Silzeq��yf '1 PM Owner's Name d `X fi+l1EZ- Address `;s/ n& WT_g�11X/�i''-Phone�Z3'� Contractor's Name �L License No. "'� "1 `o Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCfiIO ❑ PUMP INSTALLATION' ❑ SYSTEM REPAIR 111 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS VI INTENDED USE ❑ Industrial Domestic/ Private El Public '❑ Irrigation Repair Work Done ❑ Well Destruction ❑ TYPE OF WELL ❑ Open Bottom ❑ Gravel Pack ❑ Other ---Approx. Depth Type of Pump Well Diameter _ Depth PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Manteca Dia. of Well Excavation ❑ Tracy Type of Casing ❑ Delta Depth of Grout Seal ❑ Eastern Surface Seal Installed by H. P. State Work Done _ Sealing Material (top 501 Filler Material (Below 501 Dia. of Well Casing Specifications Type of Grout_ TYPE OF SEPTIC WORK: NEW INSTALLATION -REPAIR /ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is old N vailaple wi�t hin 200 feet.) Installation will serve: Re 'dence � Commercial Other oldr60 i5_"?J Cw Number of living units: Number of bedroom f/ r Character of soil to a depth of 3 feet: ��a. �i �\ Wa r table depth SEPTIC TANK 19' Type/Mfg CDP e't�'�''i� CapacitytiSC No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ACONo. & Length of lines Total length/size `FILTER BED El Distance to nearest: Well Foundation Property Line ;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 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 fol 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 which this permit is issued, I shall 'employ persons subject to workman's compensa- tion laws of California." The applica Rt mot call I or all re 'red ' s ctions. Complete drawing on reverse side. Q Signed Title: ,,�� Date: FOR DEPARTMENT USE ONILY /� Application Accepted by !ti v2 Date SA Area Pit or Grout Inspection by Date Final Inspection by to /[ Date J / 'Additional Comments: old sirqt d _ ❑ Stk 466-6781 ❑ Lodi 369-3621 anteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental WeNth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 + EH 1324 (REV. 10/83 EH 14.28 INFO FEE AMOUNT DUE AMOUNT REMITTED CK V CASH RECEIVED BY DATE PERMIT"NO. 4 s° Q_JA N p �-� s ?y i,�,5