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I� APPLICATION FOR PERMIT f 6';13 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA ".3V Telephone (209) 466-6781 ti PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete:imTriplicate) Application is hereby made to the San Joaquin Local Health District fora 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 F Local Health District. Job Address C" Lot Size eic T fi PM Owner's Name , Address Phone Contractor Address License No. Phone w . . TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El_ DISTANCE TO NEAREST: SEPTIC"TANK`x' Y' `°- -'SEINER LINES'- DISPOSAL FLD. PROP. LINE { FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEMAREACONSTRUCTION SPECIFICATIONS ❑.Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑-Domestic/Piivat ElGravel Pack ElTracy Type of Casing Specifications -❑ f ublic � L� Other ^ Y M =❑'Delta Depth of Grout Seal _ "^� Type of Grout r s _ 7-- - .. t a Irrigation l —Approx. Depth ❑;Eastern Surface Seal Installed by "Repair Done- ,- Type of Pump 1- H.P. State Work Done r { Well derludtion f ❑ Weill Diameter. S@ling Material (top 501 ;Depth - _ -Filler-Material {Below 50'1 �- ',:TYPE OF SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITION ❑ DESTRUCTION ❑ No septic system permitted if public sewer is F available within 200 feet.) Q Installation will serve: Residence— Commercial-Af' Other Number of living units: I Number of bedrooms l Character of soil to a depfh of 3 feet: Water tabie depth SEPTIC TANK B-- Type/Mfg gggr A641, r Capacityp.:(�.— No. Compartmentsdr PKG. TREATMENT PLT. ❑ i' / ; Method of Disposal Distance to nearest: Well Foundation�O Property Line LEACHING LINE 'R>-No:& Length of lines Total length/size FILTER BED �O Distance to nearest::--WeN J Foundation��.... ° Property Line ld � L; "^ SEEPAGE PITSi PY Depth C ,29� - Size yX �! Number ! i }.. SUMPS ❑ Distance to nearest: Well Foundation 4i k - Property Line./a DISPOSAL PONDS ED @?/? i I hereby certify that I have prepared this application and that th work will be done in accordanceT with San Joaquin county ordinances, state laws, and rules'and regulations of the San Joaquin Local Health District. 1 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 J employ any person in such mariner 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 m for requi94 inspections. Complete drawing on revs side. I Signed I Title: /l/d — Date: f _ F DEPARTMENT USE ONLY i Application Accepted by Date F �v Area � _ r a, It r Grout Inspection by Date Final inspection by Da Additional Comments. .... _..,�._. ❑ Stk. 466-6781`' �Lodti 369-3621 ❑ Manteca 823-714`' ❑ Tracy 835-6385 n-,'.; r r Applicant- Returns all.cdp .s'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 + EH 13-24{REV.1/85) -7010 i'J EH 14-26 p Q '7 II