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ase r . 4* r APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL—ION 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 V 'T"b0✓ 4'\ City Lot Size / '- ' " PM Owner's Name v1 r Address 6 Drh �yT Z Phone ►- ContrSC-tor'-s'Name—l'+'tQt _ ._.,�.:_..,..--. p�Ar7 "I ,cense No. _ .'' Phone 1(y�% TYPE OF WELL/PUMP: NEW WELL< WELL REPLACEMENT DESTRUCTION ❑ 'f # r PUMP INSTALLATION ❑ SYSTEM REPAI ❑ OTHER ❑ t"-MSTANCE TO NEAREST: SEPTIC:TANK -SEWER-LINES ��-�*'-^ DISPOSAL'FL�: PROP'. LINE �- ��F FOUNDATION 7Z- AGRICULTURE.WELL-2i� OTHER WELL--4 (� PITS/SUMPS M 4 5 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS w k ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation �f- Dia. of Well Casing 2 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing S& Q Specifications ❑'Public ❑ Other - ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work-Done ❑ Type of PumpOr H.P. State Work Done Well-Destruction ❑ Wel I DiXeter SeaMateri (to 501 0G �-� � -I th r erial e o TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION ❑ DESTRUCTION ❑ o septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: NumbeF,-o#bedrooms # Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 4 ❑ Type/Mfg } W I Capacity No. Compartments PKG. TREATMENT PL`. ❑ a Method of Disposal w j l Distance to nearest':' Well Foundation Property Line r i LEACHING LINE ❑ No, & Length of lines 9 Total length/size FILTER BED ❑ Distance to nearest:. t Well Foundation Property Line � t i SEEPAGE-PITS;- - ❑ Depth Size_ Number, _ SUIVIPS� `d Distance to h� are Wall Foundation v Property Line DISPOSAL PONDS O- r,. hereby certify that 1 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'Astrict. v�`a 1< Home owner or licensed agent's signature certifies the following "I certify that in_the performance of the work far 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 appliit cant mut %qui -,ns,, ctio omplete drawing on reverse sid ` t t Signed Title: ;Vr ; Date: FOR DEPARTMENT USE ONLY pplication Accepted by,A N rT`3� Area /2— Date 3 Pit ofGrout I s ction b` f pe Y Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental'Health Permit/Services 1601%E. Hbzelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE p AMOUNT REMITTED -*CK RECEIVED 8Y INFO ! CASH DATE ' PERMIT"NO. + EH 1324 I REV,10/83! $ p.�, w,-4 Q y 'EH 14-26 Q - `''2�`a�, `* - , y"Al •