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. = APPLICATION FOR PERMIT t 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. = r . t „ Job Address Citycd eteLot Size f� anPM Owner's Name 17.46- Y<�+'f t`LL_fr� Address Phone rContractor's Name Gt I "f P�a L License No. _ ,6104f Phone a - 'STYPE OF WELL/PUMP: NEW WELL OK WELL REPLACEMENT ❑ DESTRUCTION ❑ /P�1 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTACO NEAREST: SEPTIC TANK j/� SEWER LINES DISPOSAL FLD. PROP. LINE �fJ� h� UNDATION 7 f AGRICULTURE WELL OTHER WELL PITS/SUMPSG9 I TENDELI�E ' 'U E OF EL ROBLE ARfA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Ype, Bottom ❑ Manteca Dia. of Well Excavation /2 Dia. of Well Casing Domestic/Private Gravel Pack ElTracy Type of Casing__je!i .., ; Specifications !f A ❑ Public ❑ Other ❑ Delta Depth of Grout Seal L] Type of Grout ❑ Irrigation ---Approx. Depih ❑ Eastern Surface Seal Installed by AAI Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter _ Sealing Material (top 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is , available within 200 feet.) € Installation will serve: Residence_ Commercial_ Other E i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments *' PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line i I LEACHING LINE ❑ No. & Length of;lines `"" �' Total length/size FILTER BED ❑miDistanceto,Aearest:'"'""Well•'^-_-_ - - foundation' " --Property Line � I SEEPAGE PITS ❑ 4zPepth Size Number SUMPS ❑ Distance to.nearest: Well Foundation Property Line ? DISPOSAL PONDS ❑ .. hereby certify that I have prepared this.application and that the wort'will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joequiri Local Health District. 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 menner,'as_qo-become subject to workman' 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 mus f r r d ' pact ns. C plete drawing on rev a side. t' Signed i.., ' Title: f� Date: h 1 I '�E•;y,""";, FOR DEPARTMENT USE ONLY I Application Accepted by Xf Date � / Area Pit or Grout Inspection by Date ?' Final Inspection by Date a 1 Additional Comments: i ) ❑ Stk 466-6781 Lodi 369-3621 El Manteca 873-7104 ❑ Tracy 8355-63!35 Applicant- Return all cop o: Environmental Health Permit/Services' 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. INFO CASH + EH t3.24/REV.10!83} '9� � 7 , EH 14-26 Q /a f&7-