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APPLICATION FOR PERMIT ?h SAN JOAQUIN LOCAL'HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA ' Telephone (209) 466-6781 PERMIT EXPIRES1 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 we and the Ryles and Regulations of the San Joaquin Local Health District. * ; 30! 4-i Fl4V OV City PM Job Address Owner's Name /IE'� C�1�lI� Address 7/1 - .I1Qt'!097' ZZ; ._. Phone Contractor sai Address :1144041T License No. jww Phone TYrPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 71 SYSTEM REPAIR Ll OTHER ElDISTANCE TO NEAREST: SEPTIC TANK � 6o SEWER LINES IDISPOSAL FLD. "� PROP. LINE ! -,------- -'�^--FOUNDA'T1ON"""SO AGRICULTURE-WECL'—'"'""'"'"'OTHER-WELL ��PITSTSUNIPS-""-77 CONSTRUCTION SPECIFICATIONS 'INTENDED USE TYPE OF WELL PROBLEM AREA Eb Dia. of Well Casing b ❑'Industrial Open Bottom ❑ Manteca Dia. of Well Excavation . ❑ Gravel ❑ Tracy Type of Specifications, �Dometic/Private ❑ Public �,❑,��Oth�e ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation �Ap epth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.► �. Installation will.serve: ,'Residence, Commercial Other Number of living Number of bedrooms- - -- -- r Character of soil to a depth of 3 feet: "` T�--� Water table depth SEPTIC TANK ❑ Type/Mfg ! Capacity No. Compartments ` t Method of Disposal PKG. TREATMENT PLT. F1t t \ - 4 Distance to nearest: Well Fou' lation_ Property Line d ❑ No. & Len Length of lines Total-1i:ngth/size LEACHING LINE g ti FILTER BED C1Distance to nearest: well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Local Health District. tt this permit is issued+l shall not Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which 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 ompensa- k tion laws o California.- - E1 The applic '-ell required inspect ons. mplete drawing on reverse side. &'74 j Signed Title: Date: `�j i [ FOR DEPARTMENT USE aNLY C1 1C1�1 C31 ,�«...�.�-.-..--,-om.•a...-�.,. ,�.-,_.,...�-.e,.•Dafe��2�3-"-o��T Area �'� Application,Accepted by�-'�"'a` c, R Pit -Grou - pection-by ate } Final-Inspection by"� `Date Additional Comments: Al Stk 466-Ml ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,-Stk., CA 95201 FEEgMOUNT DUE:, AMOVNT REMITTED C RECEIVED BY DATE PERMIT`NO, INFO JJ'�� `^v l f + EH 13-241REV.I/a5) LJ' �� • �(a �� "+� �l L EH 1428