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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. Job Address 1e0 / t/� � � ' - --- Gity Lot Size PM Owner's Name r 07U Address Qa2_ Phone Contrac 1dwz!��W&J6 Address r� �f License No. -4 - Phone =Ja TYPE OF WELL/PUMFT. NEW WELL ❑ `WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINT= FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ,Type of Casing Specifications F] Public ❑ Other n Delta *Depth of Grout Seal --Type of Grout _ I I Irrigation _.-Approx. Depth 1 1 Eastern� ss Surface Seal installed by _ Repair Work Done ❑ Type of Pump H.P. "F� -- SOte.Work Done Well Destruction ❑ Well Diameter Sealing Maieriah#toe 50'i Depth Filler Material !Below 501 — TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ cher Number of living units: '� � � � Number of Brooms Character of soil to a depth of 3 feet: ' Water table depth SEPTIC TANKType/Mfg Capacit 7 No. Compartments PKG. TREATMENT PL . ❑ r ! Method of Disposal Distance to nearest: WellFoundation .-..44F_S::r Property Line r LEACHING LINE No. & Length of lines c Total length/size 7 X X 62r FILTER BED ❑ Distance to nearest: Wel Foundation Property LineSFEPA �1 � GE PITS 1 1 w�epth �d Size �n ifC !� 9? umber �/ r i SUMPS Distance to nearest: Wel Foundation 5 Property Line DISPOSAL PONDS Cl 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 Di%trict. 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, l 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 ust call all r quired inspections. Complete drawing on reve�rs�si� Signed X Title: il�r .�f Dater FOR DEPARTMENT USE ONLY Application Accepted by Date Area _ ©©�� pp �� Pit or Grout Inspection by bate Final inspection by 4 f Date � �� 7 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 ❑ Tracy 635-6385 �-- Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, §tk., CA 95201 FEE CIK INFO AMMO�U'NNT DUE AMOUNT UNIT REMITTED CASH RECEIVED BY DATE PERMIT NO. +.EH 13-241REV.1/85) / 0 t EH 14-26 L ` 07 �lfQ+