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i APPLICATION FOR PERMIT 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. (� Job Address U 12 Le- � '� City C� a Lot Size J Q�K ply ! Owner's Name Le.ryCos. d Address e 71 3$ d Phone i Contractor /' f 4 r f In r U PI Address f� !, ^or &MteLicense No.2360=W)� phone — V TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK 12 S�— SEWER LINES _ 1 ?S 1 4- DISPOSAL FLD. PROP. LINE I QO, FOUNDATION IDD AGRICULTURE WELL OTHER WELL _DO' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing SI II §QDomestic/Private ravel Pack ❑ Tracy Type of Casing Specifications 1 i'I Public fl Other rFI ` Delta Depth of Grout Seal ()C? Type of Grout I Irrigation .Approx. Depth [ I Eastern Surface Seal installed by f Repair Work Done ❑ Type of'Pump ! H.P. State Work Dane_ Well Destruction 7(1- Well Diameter V - Sealing Material (top 50') - Depth �r. ' P Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is ` available within 200 feet.) V) I Installation will serve: Residence_f Commercial_. Other Number of living units: Number of bedrooms _ c Character of soil to a depth of 3 feet:, .-T" sa_ Water table depth 02 SEPTIC TANK ❑ Type Mfg Capacity No. Compartments PKG. TREAThifENT PLT. ❑ Method of Disposal t /1 - y Distance to nearest: Well` Foundation Property Line �/ J l r LEACHING LINE CNo-&..Length of lines t Total length/size FILTER BED a d ❑ Distance to nearest: r Well — — Foundation Property Line - r SEEPAGE PITS 11 Depth Size Number SUMPS ~ ' £�1 v fie„ 1 L�""Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Ll 1 hereby certify that I have prepared this application and that the work will be done in accord~ a'�nce fI San^ Joaquin county ordinances, state laws, and L rules and regulations of the San Joaquin Local Health DFstrict. r A, Home owner 6 licansad agent's signature certifies the following:"I dertifq"thai`inthe performance of the tivork for which this permit is issued, f shall not _ employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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`applicar `r1i s �ca`p'foi all requirei9'ihspections—Complete-dra ing on reverse_side. Signed X J Title: _.ZG/�3 Date: — t]R DEPARTMENT-USE ONLY �� ~ Are 2 0S, �� - Application Accepted by � Date Pit orrou. Inspection by Date Final Ins ection b _ p y Date Additional Comments: - !/,�i i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71 ❑ Tracy 835-6385 Applicant- Re II copies to nv'onme I Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 200Stk.; A 9501" c► �j y INFO AMOUNT DUE AMOUNT RE ITTED CK RECEIVED BY OATS s , CAS H PERMIT'NO. ♦.EH13-2401 EV.1/95) �N 6? 2- EH 14-26 .r