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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (2091 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. lot Size PM , .... , c , a , Owner's Name Ad' 6 a. a A _,..., Address Phone ,. ....ria--44-"-42.--- - Contracte rilie.-± Address Piaalik_124/41.&-O---• 31-3° L((icense No ‘ --- Phon)- (71 , TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT 0 DESTRUCTION 5 PUMP INSTALLATION A4 SYSTEM REPAIR CI OTHER C DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I_J Industrial LI Open Bottom C Manteca Die. of Well Excavation Dia. of Well Casing il Domestic/Private CI Gravel Pack n Tracy Type of Casing Specifications fi Public Ell Other Fr Delta Depth of Grout Seal Type of Grout i I Irrigation Depth I I Eastern Surface Seal Installed by __Approx. Repair Work Done ( Type of Pump H.P._,:te..,e..--- State Work Done A:144.4•24//72'15,,:j #414‘...i.e-- Well Destruction il Well Diameter Seating Material (top 50') Depth • ' Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I No septic system 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: Water table depth SEPTIC TANK 5 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. CI Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FITTER BED 0 Distance to nearest: Well Foundation Property Line , SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line -....... _ __. DISPOSAL PONDS ril Date -4.67=-1 — fZ) /Area 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 g rules and regulations of the San Joaquin Local Health DiMrict. 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 California." The applicant must c I for all rag "red inspections. Complete drawing on reverse side. Signed X - Title: / DEPARTMENT USE ONLY -e-0.-•— Application Accepted by 'll Date Pit or Grout Inspection by Date Final Inspection by Additional Comments. LI Stk 466-67E11 0 Lodi 369-3621 0 Manteca 823-7104 CI Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 EH 13 24 fREV. ir 1 51 EH 14-28 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT' NO ''. ' -C..- 1---<h,.,--• ka9 /