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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.—JON 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. !� o Job Address�doC 33— w_[�� - -1�� City Lot Size�•g �' .PM ' Owner's Name Etta `'►-� .4 10 Address 1��35' 1U• C�[�'C� Phone Coritract c Lai Address P0, &Ai 74-7 License No. g �Cc Phone TYPE OF WELL/PUMP: s NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK .SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS - 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type ofCasingSpecifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —L4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pumb H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth ` Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW-INSTALLATION ❑ EPAIR/ DDITION DESTRUCTION ❑ (No septic system permitted if public sewer is N available within 200 feet.) W Installation will serve: Residence Commercial_ Other Number of living units: I Number'of bedr ms _ Water table de Character of soil to a'depth 6f-3 feet: depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 4"Y , - I .171 Method of Disposal Distance to nearest: Well- _ - Foundatiori` _ Property Line i LEACHING LINE -�—O--No:-&-L-ehgth of lines - - — Total length/size 7 ; FILTER BED ; ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ DeptK, Clc2 Size x y Number SUMPS tr 9?' Distance to nearest: We€I -;Foundation /0 Property Line DISPOSAL PONDS ❑ �' Y I hereby certify that I have prepared this application and that-ihe 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 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 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 t call for a req ired inspections. Complete drawing on reverse s' e. Signed Title: �r. Dater FOR DEPARTMENT USE ONLY 1 Application Accepted by i Date, A 1 10 Area Pit or Grout Inspection by Date [ Final Inspection by ZI& Data I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M •a, Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.0- Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 1324(REV.r/85) 1�� 97443 EH 14,28 d