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APPLICATION FOR PERMIT f�lcf s9 SAN JOAQUIN LOCAL HEALTH DISTRICT • it 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 j 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.2/`s-) lj4City Lot Size PM Owner's Name W CJVu-� � .k :§I�ddress Ir t + 3 Y 6' Phone 3 3 Y— _)6 1 v Contractor 10 F' Address4 4 License Nof( x-31 3 Phony f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i f I Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout I4'lrrigation _Approx. Dl th I 1 Eastern Surface Seal Installed by � Repair Work Done 40 Type of Pump��' H.P. 1 U State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 1 Depth Filler Material (Below'50') ®f"1 TYPE OF SEPTIC WORK; NEW INSTALLATION 11 REPAIR/ADDITION I ) DESTRUCTION l I Wo septic system permitted if public sewer is I I available within 200 feet.) i Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms x p -- ---- ---r— —..Water`tab depth .Character of soilto�a�de-depth t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments v a r P.KG. TREATMENT PLT, ❑ f Method of illIi§pcj�slt a �r,r i Distance to nearest: Well Foundation Property Line E LEACHING LINE ❑ No. & Length of lines Total length/sizeMAY 01989 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number -i`S`'Il�t_;'v?;I�NTTLt,L HEMA! SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ N ! I hereby certify that I have prepared this application and that the 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." F I The applican us call for all equired inspections. Complete drawing on reverse side. '-l� I Signed X ___— - _ -T. aitle: Date: M1 FOR ARTMENT USE ONLY70 u d° Application Accepted byDate Area t� 1 ; Pit or Grout Inspection by Date Final Inspection by Date �' ! Additional Comments: LI Stk 466-6781 ❑ Lodi! 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6386 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009;-,Stk., CA 95201 CK FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17'NO. +.EH 13-24 IREV.I/H 5] EH 14-28 1-6//31 A212 ;i ,