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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZELTON 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. ,f �/ // !_ f Job Address -70 0 z � ,4 7" City 10A� Lot Size �` �? PM ! ✓ + Address 2-l) �� .hone Owner's.Nam//e .gyp / Contractor 1, %T?!1yV.1f1 Address 6 r Uof License N / Phone 35 TYPE-OF WELL/PUMP: NEW WELL,CI.•,,,••„�_ . ` WELL REPLACEMENT_ DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR,ET OTHER ❑ ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES "DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL= —. PITS/SUMPS l INTENDED USE TYPE OF WELL PROBLEM�AREA CONSTRUCTION SPECIFICATIONS: ' v: ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 (� ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications s� ❑ Public " n Other .F1 Delta Depth of Grout Seal Type of Grout R I I Irrigation —,Approx. Depth- "t I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H:P. State Work Done Well Destruction ❑ Well Diameter" _ Sealing Material (top 501 �. Depth = Filler Material (Below 501 ' �s TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1_1 DESTRUCTION l 1-INo septic system permitted if public sewer is r� available within 200 feet.) Installation will serve: Residence Commercial_ ther # l Number of living units: Number o�bedroo Character of soil to a ep>yh of 3 feet: �' ` Water table depth 1{ SEPTIC TANK Type/Mfg L, Capacity %Al"d ( No. Compartments ` PytG. TREATMENT PLT ❑ Method of Disposal l Distance to nearest: Well +Foundation •5 Property Line n ACHING LINE . No. & Length of fines C.�4 Jam,%,— Total length/size N ILTER BED ❑ Distance to nearest: ell Foundation �� / Property Line i } SEEPAGE PITS FI Depth 2 Size Number, :3 -- SUMPS "" Distance to nearest: Well Foundation_.y._._. Property Line fb 1f DISPOSAL PONDS ❑ r I hereby certify-that-t•have prepared this application and that the work wd 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 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 subcontracting 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 workma�o's compensa- tion laws of California." x1 The applic m corlbr all quire FR f s. Comple awing on reverse side. Signed X i (G / Title: /z+tet/; 7�� Date: FOR DEPARTMENT USE On/Ly Applicata Accepted by4rf:�ek Date~�`� ^ � f x Area Pit or GYout Inion by ate Final Inspection by Date ? — " C/ i� / , ��*/ Additional Comments: d ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7184 ❑ Tracy 835-6385 Applicant - Return all copies to: 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 + EH13-24(REV,1/85) r r, f �y EH 14.26 �h / gq—D-1