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APPLICATION FOR PERMIT SAN JOAQUI4N 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 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. t {_ {� Job Address 3 Ste_ _1�ct, - Dip. City %eLot Size PM Owner's Name ��l��Ql` 5� l,Q(L��_ Address - �_&d_-rG yee _ Phone _ Contractor's Name ai,AA License No. _ Phone 7 (, TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i� PUMP iNST� LLLATION 171——µms SYSTEM REPAIR ❑ ^ ' OTHER El-' l DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION _ _ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial + ""'D Open Bottom -E] Manteca Dia. of Well Excavation Dia:of Weil Cesing- ❑ Domestic/Private -1 Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public 1 !J Other ❑ Delta Depth of Grout Seal __- Type of Grout ❑ Irrigation t ---Approx. Depth ❑ Eastern Surface Seal Installed by ' Repair Work Done ❑ Zypg of Pump lJ r t - 0 t' IWID �Yr_ State Work Done Well Destruction ❑ '-Well Diameter ��_"'�� _Sealing Vaterial (top EO') _ Depth Filler Material (Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system ystem permitted if public sewer is available within 200 feet.) { Installation will serve: Residence_' Commercial_�/Other Number of living Units:, Number of bedrooms Character of soil to a depth of 3 feet: +-� W51ei falile'c7epth•' SEPTIC TANK }; Type/Mfg _ f�. JCapaci °NrrrCo'rnartments PKG. TREATMENT PLT; F_ '` i` y A� i� y dth d 'f-Disposal �` Distance to nearest: ell _ Foundait perty l s2 � LEACHING LINE ❑ No. & Length of lines Total length/size r y FILTER BED ElDistance to nearest: Well Foundation Property Line J r � I SEEPAGE PIT$ ' L�' Depth 9's `,Size Number SUMPS I l COistancb to nearest: Well Foundation Property Line DISPOSAL FINDS .ff'4J { I hereby certify' that I have prepared this application and that the work wil be done in ac ord wit an Joaquin ounty ordinances, state laws, and rules and regurhb Tof 1Ke'S8r Joaquin Local H6b th'bistrict. 1 �, j Home owner or licensed agent's signature certifies the following: "I certify that4n the performan tthe' r for which this permit is issued, I shall not { employ any person in such manner as to become subject to workman's compensation laws-t f`California." Contractdrr's+hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for whi6 this permit is issued,.)shall embloy persons subject to workman's compensa- tion laws of California." The applican st cal f all required inspections. Complete drawing on,reverse side. Signed X 65ne1__ Title: 9fin—yd EA V.AA e—e r Date: FOR DEPARTMENT USE ONLY T'N1 (• f S -�" ( Application Accepted by �'^-Date �. Area 1 Pit or Grout Inspection by ate �� Final Inspection b Date �� v { Additional Comments: Stk 466-6781 El Lodi f3ft3621 ❑ Manteca -7104 1 ❑ Tracy 6385 App is nt - Return all copies to: Environmental Health Permit/Services 1601 E.,Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO SH MOUNT DUE AMOUNT REMITTED CA3FI ... RECEIVED BY DATE PERMI�TT'NO. 4 EH 3-24EH 1428 iREV. 10/83) / D �»•+".r -""� �,-