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t s APPLICATION FOR PERMIT = SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 v PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I .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 0 S- City STT tl7aIr-'Lot Size PM �{ Owner's Name a Address 1l�'7�fja!I A yFr- _ Phone 4-— 7-0— Contractor Contractor �c'�i�= _ _Address License No. Phone TYPE OF WELL/PUMP: 1NEW WELL ❑. WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑.;-" SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK "SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS \ INTENDED USE TYPE OF WELL l PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bostom i ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ` ❑ Tracy Type of Casing Specifications M Public Cl Other s ❑ Delta Depth of Grout Seal Type of Grout . I 1 Irrigation _.Appiox. Depth I 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material atop 50') a Depth t Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRlADDITION i.l DESTRUCTION (No septic system permitted if public sewer is -available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK .❑ Type/Mfg - - M --Capacity - No. Compartments PKG. TREATMENT PLT. ❑ Y Method of Disposal t 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 l I Depth 1 Size Number SUMPS D 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 V rules and regulations of the San Joaquin Local Health District. s 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 which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." FI The applicant m st call for required inspections. Complete drawing on reverse side. I iC SignedX �-.� � Title: e22w JATL _____ ____ Date: 12 -1 —97 - 1` FOR DEPARTMENT USE ONLYud4 Application Accepted by Date �� 1 Area Pit or Grout Inspection by Date Final inspection by l' Date�� Additional Comments: -r�l �o ,�1,.� >f/1`r,do)Vcr� , GI?M �/I/ _S 1!6 ❑ Stk 466-6781 ❑ Lodi 36-3621 ❑ Manteca 823-7104 ❑ Tracy 839-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ONFEE AMOUNT DUE AMOUNT.REMITTED k,CK RECEIVED BY DATE PERMIT-NO. INFO ♦ EH 13-24 IHEV.1 45) � - 3S,c� `�✓� 1 �,� 1�1�� AAWa EH 11-28