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Q� v7d � . i' APPLICATION FOR PERMIT = I� SAN JOAQUIN LOCAL HtALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA l Telephone (209) 466-6781 i 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 Ryles and Regulations of the San Joaquin Local Health District. *1 F y Job Address _ City' Lot Size PM Owner's Name ��'2X_. I'L-�^iG77Address' Address fc� . 5<.3q�Phone Contractor License No. 2E _ TYPE OF WELL/PUMP: � NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑--) -71 OTHER C1DISTANCE TO NEAREST:"SEPITIC-TANk SEWER LINES 147' DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELCH? W OTHER WELL PITS/SUMPS - II` INTENDED USE. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial 3 '-❑'Open-Bottom ElManteca Dia#of Well Excavatio Dia. of Well Casing ❑ Domestic/Private ❑ Glravel Pack Ll Tracy Type of Casing „ Specifications ❑ Public ❑ Other ❑ Delta -Depth of Grout Seal Type of Grout j ❑ Irrigation _IM pprox..Depth ❑ Eastern Surface Seal Installed by Repair Work Done E3 Type of Pump H,P. _ L State Work Done Well Destruction ❑ Well Diameter ) 2 Sealin-- Matefial (top'50'I PLL14 - �� Depth d ?; Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is t available within 200 feet.) Installation will serve: Residence_ Commercial� OtheIr �A Number of living units: . Number,of bedrooms - w' ` I i Character of soil to a depth of.3 feet f -` -• F Water table depth ;- SEPTIC TANK F-1 Type/Mfg L1{ 'Capacity No. Compartments PKG. TREATMENT PLT. El 1 Method of Disposal - .� N., Distance to nearest: Well FoundationProperty Line LEACHING LINE ❑ No. & Length of lines r 14 Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line I Ii C^ _ 1 SEEPAGE PITS Cl Depth Z- -Size -° - Number SUMPS {J `Distance to nearest: Well`� - Foundation 'z %.Property Line DISPOSAL PONDS 11 �!. fir- c R` 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.- oaquin Local Health District. i Home owner or licensed agent'ssignature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall note I employ any person in'such matinee 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." rf . r.The applicantfmust call for all)required inspection Complete drawing on reverse side. Signed ` Title: Date: CQ GC— �I FOR DEPARTMENT USE ONLY kl �^ 191 Application Accepted by "� J Date ��d. 9 Area N56.., 0�2 7 Pit or Grout Inspection by:' Date 3 Final Inspection by Date aF Additional Comments: ❑ Stk 466-6781 d Lori 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. - + EH.1 -24iREV.i/95INFO l • EH t440�-2a V