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APPLICATION FOR PERMIT u Q SAN JOAQUfN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (2091 466-6781 MAR 2 2 1993 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Compiete in Triplicate) EWRONMENTAL HEALTH PERMIT/SERVICES 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 15M CA4 /I64-r&1104 FMA City Tm Lot Size I ,X I W/PM Owner's Name 9011 01� IAfDD1'ti7Gry'I -- AddressW T�'n ��K�[� .•"�� Phone �� -Z� Contractor �pndlNirr+r�` � Address U14 -b-it la to U! Tll License No.u61-!5 I 3IPhon4-7'r 374•4-3bD TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT u DESTRUCTION a L3 PUMP INSTALLATIO�N'' ; SYSTEM REPAIR 0 OTHER jk(1L(N I bF4 ilk E,4 .%L&V1 4s I DISTANCE TO NEAREST: SEPTIC TANK NIIL6 SEWER LINES M DISPOSAL FLO. 1141 PROP. LINE -LOLL! FOUNDATION r7Dr AGRICULTURE WELL •OTHER WELL Hl1F PITS/SUMPS 'fyl X INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r, i-; Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Exca tion 1 Dia. of Well Casing Ci Domestic/Private 0 Gravel Pack %Tfacy Type of Casing h -Jo fVe Specifications AA/J`'',�` i'. Public l-1 Other n Delta Depth of Grout Seal �7 Type of Grout r� Cy►JCrlf I ! Irrigation 26�Approx. Depth i I Eastern Surface Seal Installed by �a Repair Work Done Ll Type of Pump H.P. State Work Done Weil Destruction 0 Well Diameter Sealing Material Itop 501 Depth Fitler Material (Below 50') T OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted it ublic sewer is available within 200 tee Installation will se Residence— Commercial — Other Number of living units: mber of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Ca No. Compartments PKG. TREATMENT PLT. 0 e— Method of Disposal Distance to nearest: Well o tion Property Line LEACHING LINE C1 No. & Lengthroes Total Ie size (� FILTER BED U dist to nearest: Well Foundation Property Lr w �SEEPAGE PITS I i Depth Size Number SUMPS 1-1 Distance to nearest: Weil Foundation Property Line DIS AL PONDS 0 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. 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." Contractors hiring or subcontracting 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 ust I for II req spections. Complete drawing on reverse side. /� !! L Signed X ' Title: f r CDate: OR DEPARTMENT USE ONLY Application Accepted by Date Ar.,S I /'-)f 7(1�j Pit or Grout Inspection by ate Final Inspection by t Date Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621 Cl Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO /FLEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO. Eli 17-T�(REV.+•w§,#// V � y CASH s� F