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R f 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 p; r (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 r [_ '?• r�nJs 4 „• ^ " Q ac V: / City { L Lot Size PM Owner's Name 14941.FQ1u f � vrLy=- Address V ` >}tf ph'.. 3 aZ I` 0 Contractor 1IIr Address License Na. Phone TYPE OF WELL/PUMP: I� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION .❑ SYSTEM REPAIR [IOTHER ❑ DISTANCE TO NEAREST: SEPT �IC TANK SEWER LINES DISPOSAL FLO. PROP. LINE .41 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPiE OF WELL ' PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial F-1 Open Bottom ❑ Manteca Dia. of Well Excavation ElDomestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing Type of Casing Specifications ❑ Public 11Othier LJ Delta Depth of Grout Seal ❑ Irrigation -A Type of Grout pprox. Depth ❑ Eastern Surface Seal Installed by , Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filter Material (Below 501 _ TYPE.OF SEPTIC WORK: NEW�INSTALLATION" REPAIR/ADDITION ❑ DESTRUCTION El (No septic system permitted if public sewer is l 't available within 200 feet.) Installation will serve: Residence y— Commercial_ Other Number of living units: IN Number of bedrooms-- Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg ✓' N C li .10 0 Water table depth i a Capacity C No. Compartments PKG. TREATMENT PLT. ❑ t T i w 1! �� . y - tr , t _ � , Method of Disposal, A Distance to nearest: Well 1 Foundation A a Property Line '� I - -- LEACHING LINE C7 No.i�& ✓ength of lines �t Total length/size FILTER BED ❑ Distance to nearest: Well /�Q` Foundation_al 1 _ property Line SEEPAGE PITS ❑ DepthSize ; f ! Number SUMPS ❑ Distance to nearest: -Well Foundation Property Line DISPOSAL PONDS ❑ IN 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 bistrict. 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 lworkman's•compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify thatin the Performance,of the work for' issued,wkich this permit is issd,I shall employ persons subject to workman's compensa- tion laws of California." +tea'i j err•sa k , The applicant ust call for all require spections. Cmple-te drawing on reverse side. Signed g ;, ) - Title: k Date: FOR DEPARTMENT USE ONLY Application Accepted In Date Area Pit or Grout Inspection by !� Date L Final Inspection by Additional Corrilnents: I� ❑ Stk;H 466-6781 t, ❑ Lodi 3533621 ❑ Manteca 823-7104 ❑ Tra 8356385 -- F..« .... �..__.-.._key. ._ Applicant- Return all copies to: En rronmental Health Permit/Services 1601 E..Hazelton Ave., P.O. Box 2009, Stk., CA 95201 tF I FEEI 6, 11 INFO AMOUNT CUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'N0. + EH 13-24LV:1/95) EH 10.26 / • �qg /�! f