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s k` i APPLICATION FOR PERMIT SAN JOAQUIN"LOCAL HEALTH DISTRICT e 1601 E. HAZE T ON 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. 6( VI Job Address —I�J i � -=�— - City-- ! Lot Size PM Owner's Name _ f i �t�41& ��("r"t7 b Address 72b, �� p /_(f�` ��I 9 �j�3 ry � "t Contractor IL ' Address (r7 l�1 {� � �`'� License No, f�� r F Phone�J�� TYPE OF-WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑.,- - --,—SYSTEM REPAIR ❑ OTHER ❑ C�-1 DISTANCE TO NEAREST:. SEPTIC TANK # SEWER LINES DISPOSAL FLD. PROP. LINE �} 'p FOUNDATION f AGRICULTURE WELL OTHER WELL PIT5ISUMPS INTENDED USE TYPE OF WELL 4 PROBLEM AREA. CONSTRUCTION SPECIFICATIONS ❑'Industrial ❑ Open Bottom ❑ Manteca _ -Dia.-of Well Excavation Dia. of Wel{ Casing i ❑ TType of Casin ❑ Domestic/Private ❑ Gravel Pack racy YP g Specifications f`l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I i Eastern_ -rW Surface Seal Installed by r State Work Done Repair Work Done 0 Type of Pump H.P. ' Well Destruction EIWell Diameter Sealing'MaG6 I (top 50') A Depth Filler Materia (Below 501— - TYPE OF SEPTIC WORK: NEW INSTALLATION WE_PAIR/ADDITION l I DESTRUCTION (.1 (No septic system permitted if public sewer is Y' a available within.200 feet.) T r� Installation will serve: Res'i.dence ,Commercial Other y n Number of living units: Wil— Number of bedrooms I i Character of soil to a eQ h of 3 feet: IA-- f Water table depth SEPTIC TANK Type/Mfg 9-'4. Capacity No. Compartments Z PKG. TREATMENT PLT. Method of Disposal Distance to nearest: Well Foundation j� Property Line y LHING LINE . J No. R Length of lines 5 �^� J�� - 'Total length/size' EAC r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS' X Depth Size Number SUMPS ' ❑ Distance to nearest. Well Foundation Property Line DISPOSAL PONDS '+❑ i 1 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 Di1trict. 4 Home owher 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 pf Calif rn' The applica u t�c for I r d in ctions. o eta drawing on reverse siyd�e.� r f /1 Date: Signed X Title: — r !t.rr� o FOR DEPARTMENT USE ONLY - Date Application Accepted by� A ti N r Arae Date Final Inspection by Date �r Grout Inspection by t� Q Additional Comments: ❑ S[k 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, S1k_/CA 95201 CK FEE AMOUNT DUE AMOUNT REMITTED CA5H RECEIVED BY DATE PERMIT NO. INFO t 7 +.EH 13-24 4REV.1/95) P EH 14.28 �r b 4/