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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 r I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t (Complete in Triplicate) t � 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. J Job Address 15 9 oo ,� L � � City 1'y� Lot Size PM Owner's Name 1R tbpr+ J;AJlG3ra Address ` 0 Phone 5s- 1 ago �r�eJ e � Contractor Address k License No MF3 k_Phone -566/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REP ACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 --� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications --Z M Public ❑ Other 41 ❑ Delta Depth of Grout Seal Type of Grout I i Irrigation - ,�..Approx. Depth { I Eastern Surface Seal Installed by o Repair Work Done ❑ -Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION ( I DESTRUCTION (No septic system permitted it public sewer is /'available within 200 feet.) Installation will serve: Residence� Commercial_ Other Number of living units: 4— Number of bedrooms Character of soil to a depth of 3 feet, Water table depth SEPTIC TANK' 0K, Type/Mfg Capacity uh bw No. Compartments PKG, TREATMENT PLT. ❑ 1 J Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size �— FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth ' Size Number SUMPS 0 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 taws, and -13 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."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 call for all required inspections. Complete drawing on reverse side. Signed X G Title: Date: FOR EP T USE ONLY Application Accepted by data CJArea Pit or Grout Inspection by Data Final Inspection by Date��-- Y7 . f � c Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED .t CASH RECEIVED BY DATE PERMIT"NO. + EH13"24(HEV,1/85) yr / EH 114-M �21 d �;7 {