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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 TYEAR FROM DATE ISSUED i (Complete in Triplicate) 3 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 _ } i Local Health District. 1�Job Address :� Y3S3 R,*) ;,�_;'S /V J19? _V 3r c+/ City rpwcY Lot Size 7.00�jFCYgS PM J Phone C r� HQ L!!fr°/fl Address S.9M 6 .. Owner's Name , Contractor-.A' /W.M!IV -.t($0.,v . -Address (�GtI a .. .v e. v�!- 141J&._..-License No. i�Y. phone S_Ay_y'9/-� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑}+� DESTRUCTION ❑ f , PUMP INSTALLATION ❑-r »-• -SYSTEM. •REPAIR19-� - OTHER L1 + DISTANCE TO NEAREST: SEPTIC TANK�' SEWER LINES DISPOSAL FLD, PROP. LINE tit FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS - 1 INTENDED USE TYPE OF-N7ELL- PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial - ` ❑ Open Bottom___ ❑ Manteca J Dia. of Well Excavation ' 'Dia. of Well Casing FI Domestic/Private ❑ Gravel Pack' ❑ Tracy Type of Casing Specifications I'1 Public 1� Other t n Delta Depth of Grout Seal •Type-of-,Grout�. — W I I Irrigation —,.Approx. Depth I 1 Eastern Surface Seal Installed by f� - 'R.,, Repair Work Done ❑ Type of Pump H.P. State'Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1_ _ Depth Filler Material (Below 50') - TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION X DESTRUCTION,[,I.,(No"septic•.system permitted if public sewer is t available within 200 feet.l Installation will serve: Residence L Commercial Other _' rT� :- �. .'� 14� { �` 'IVumber`of living units��F�- Number of bedrooms Character of soil to a depth of 3 feet: S�A� Lr0,*A7 Water table depth 'a f 1 SEPTIC TANK U Type/Mfg I�Y�' C,# Capacity/90p No. Compartments Method of Disposal ,5; PKG. TREATMENT PLT. ❑ Distance to nearest: Well ! Foundation--1-F•' Property Line #� LEACHING LINE Vor No. & Length of lines ;t " /DO Total length/size t90 FILTER BED ❑ Distance to'nearest: Well Foundation _P.roperty-,Line. -- SEEPAGE PITS i I Depth Size 4< Ava, X !r' Number t , SUMPS 111Distance to nearest: Well 2100 Foundation Property Line DISPOSAL PONDS ❑ I 1 � 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 fallowing: "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 of sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant mus call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: r� Oe DEPARTMENT USE ONLY Application Accepted by Date Area —2- I Pit or Grout Inspection by7;4Date Final Inspection by ate I Additional Comments: CL TL El Stk 466-6781 ❑ Lodi 369-3621 ❑ Ment 823-7104 ❑ Tracy 835,6385 r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO +. CASH EH 13-241REV.1/85) �� 0 19'14' r�} f� EH 14-26