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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 Sari Joaquin County Ordinance No. 549 for sewage or No 1862 for well/pump and the Rules and Re4lulations of the San Joaquin Local Health District. Job Address _. 81 —�_— e f-C,�cG (- Q-&r_ City �-C r Lot Size PM Owner's NameA -yQ ---� t_�t -- Address - '- C Lf-;-11G_ Phone Contractor -E.X' CA3�.St. CJ� 5Address 41(E�C,,kn--A t � `f -�.�rffe No. ,r.�w- Phone(J/L_ TYPE OF WELL/PUMP: NEW WELL C) WELL REPLACEMENT D DESTRUCTION FI \ PUMP INSTALLATION [ SYSTEM REPAIR L7 0 J OTHER � orgy r Io rt rL� DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES -_—__ _-___-- DISPOSAL FLD._ PROP. LINE FOUNDATION —_ AGRICULTURE WELL OTHER WELL PITS/SUMPS ------- --------- ---- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (' Industrial L) Open Bottom ❑ Manteca Dia. of Well ExcavationiT � z/ rz 8 Dia. of Well Casing Domestic/Private U1 Gravel Pack D Tracy Type of Casing_��_� ��V(�Specifications CCr�r_,� i i Public (1 Other 11 Delta Depth of Grout Seal �'-� �ye fc 11 p -- Q_j of Grout Irrryfation --_- Approx. Depth I I Eastern Surface Seal Installed by 1 I Repair Work Done O Type of Pump H.P. State Work Done _ I+ Well Destruction [ l Well Diameter i —�}__— Sealing Material (top 50'{ C-rnct-k:�' "L .�j�y_� 'i _, - tUrI��o rt t� 0-11 Depth ^' to�..• 7y� Filler Material (Below 50'! �c TYPE EPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) n Installation will serve: Residence— Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ElType/Mfg Capacity No. Compartments PK/G. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well �_ Foundation Property Line LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED 11 Distance to nearest: Well _ _ Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS I_I Distance to nearest: Well ._ Foundation Property Line DISPOSAL PONDS 11 I 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 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 rnia." The appy nt st cal for requir inspections. Gea�lete drevvirl� �l rrz l J nq Signed Title: p ^ _ Date: 0y p A- �� FOR DEPART USE ONLY Z Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: II Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O Tracy 835-6385 Applicant -t Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 rINFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY GATE PERMIT NO. / i.