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C, APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 t PERMIT EXPIRES 'I YEAR FROM DATE ISSUED (Complete in Triplicate) I 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 i Local Health District. Job Address �� City=51�'� Lot Size.IV � 9 _ PM r Owner's Name �a � �� I� 'Address° Z ewi'vdi n ",. ' Phone , y %If` Licens No.�Kyff Z9 Phone "4 Contractor's Name I TYPE OF WELL/PUMP: NEW WELL C3WELL REPLACEMENT EJ DESTRUCTION ❑ k PUMP INSTALLATION L3SYSTEM REPAIR Elr i,,'OTHER.❑ ""' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD— w PROP. LINE FOUNDATION AGRICULTURE=WELD OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA-` 'CONSTRUCTION SPECIFICATIONS ' ❑ Industrial 1-1Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing# El Domestic/Private ❑ Gravel Pack ❑ Tracy Type'of-Casing Specifications ❑ Public ElOther ElDelta Depth of Grout Seal Type of Grout W ❑ Irrigation __--Approx. Depth El Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done W Well Destruction ❑ Well Diameter Sealing Material (top 501 a Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ available septic syst m permitted itted if public sewer is' Installation will serve: Residence_ Commercial 'Other Number of living units: Number of bedrooms i �.1Water table depth_�a��'�� t Character of soil to a depth of 3 feet: t SEPTIC TANK ❑ Type/MfCapacity-42 10 do No'. Compartments _ II PKG, TREATMENT PLT. ❑ r Method of Disposal 1� Distance to nearest: Well Foundation /Q Property Line ss I M � rt LEACHING LINE No. & Length of lines - Total length/size FILTER BED ❑ Distance to nearest: Well j!?jk2— Foundation 40 e— Property Line. SEEPAGE PITS Lam" Depth i Z E —Size Number— ' SUMPS ❑ Distance to nearest: Well Foundation /!? f 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. fir` 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 F employ any person in such manner as to become subject to workman's compensation laws of California.-Contractor's-hieing or supe&tracting signature certifies the following:"I certify that in the performance of the work for which this permit is issues`shall employ,persons subject to workman's compensa- tion laws of California." u The applicant call for all required ins ctions Complete drawing on reverse s' e. Signed T— Title: ate: 11 tFOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by —Bate `r t, Final Inspection by co �'• to Additional Comments: j ❑ Stk 4664MI ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy��-6386 ,� Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.-,Box 2009, Stk., CA 85201- FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BYE DATE PERMIT NO. ` INFO + EH 1324 MEV.10/83y EH 14-26