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r I I + l APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-67$1 k PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f (Complete in Triplicate) j 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 f 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 v City �—+ 0 Lot Size,/_nar_33 �Owner'ss Name A ,[A_z4 1111 ! /2-1- Address J /`! Phone j Contractor's Name D Micense No. Phone _2V1991Z3_. f TYPE OF WELL/PUMP: NEW WELL fir_ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION n~ SYSTEM REPAIR ❑ OTHER ❑ _ DISTANCE 70 NEAREST: SEPTIC TAN KQ SEWER LINES DISPOSAL FLD. PROP. LINE v FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Ind I ig^ffp@n Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing S^ ie O_luestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing L Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of out ❑ Irrigation Approx. Depth astern Surf Seal Installed by Repair Work Done ❑ Type of Pump ?s H.P. State Work Done 1� i{ Well Destruction ID Well Diameter Sealing Material Itop 50'1 V Depth Filler Material (Below 501 (� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is U 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 Capacity No. Compartments PKG. TREATMENT PLT. ❑ ,< Method of Dispose! Distance to nearest: s Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines L,. Total length/size FILTER BED ❑ Distance to nearest: ', Well Foundation Property Line �,. SEEPAGE PITS ❑ Depth „"+Size Number SUMPS ❑ Distance to nearest: .;' Well Foundation Property Line DISPOSAL PONDS ❑ r I hereby certify that I have prepared this application',�ind that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Heoh District. Home owner or licensed agent's signature certifies te 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 suT)ject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature I 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 at 11 for all required inspections` plete drawing on reverse side. Signed Title:_ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 3 9 7 Area Pit or Grout pection by Date Final Inspection by oe Date /� t Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-36211D Manteca 8,23-7104 ❑ Tracy 835-M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO RECEIVED BY DATE PERMIT"NO. + EH 13-24(REV.10/83f `e �� T 7 771 i EH 14.26 1` �� . -5id / +7� � 7 %7 +7'S•�