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k APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT s . . i -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 Ryles and Regulations of the San Joaquin Local Health'District. :'s .S�i�/✓`' T Loi Size C A)Ir /4 PM Job Address City Owner's Name.�AV 1 D �� "- -- Address-X5.2 OR � ��2 i �- _ Phone ' .p. �0 License No. Phone - 60 Contractor � �S Address TYPE OF WELL-/PUMP:, NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ WSTEM REPAIR ❑ OTHER LJ PUMP INSTALLATION ❑ SY .... s DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES x DISPOSAL FLD. POOP. LINE FOUNDATION T AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL -- PROBLEM PROBLEM AREA CONSTRUCTION SPECIFICATIONS LJ Industrial L!Open Bottom -¢,❑.Manteca Dia. of.Well Excavation Dia. of Well Casing s Type of Casing— Ll asin Specifications ❑ Domestic/Private E3 Gravel Pack 12 Tracy" yp g LlPublic ❑ Other d Delta Depth.of-Grout Seal Type of Grout ` Ll Irrigation ---Approx. Depth . ❑ Easternr� Surfaae-Seal Installed by .!�' Repair Work Done 17 Type of Pump H P:. k State Work Done Well Destruction ❑ Well Diameter Sealing-Materiai (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Jill_DESTRUCTiON-❑..•(No septic system permitted if public sewer is 5 4. ;available within 200 feet.) Installation will serve: Residence X Commercial_ Other r Number of living units: Number of bedrooms # k Character of soil to a depth of 3 feet: ASO C3 I s Water table depth SEPTIC TANK ❑ Type/Mfg cn041 rZF_TF_ -} Capacity No. Compartments PKG. TREATMENT PLT. ❑ ' ' Method of Disposal Distance to nearest: Well 100 Foundation 30� Property Line 'TO y 1 Ir 1 $ LEACHING LINE N No. & Length of lines � Total len gth/size 04 I1 FILTER SED ❑ Distance to nearest: Well Foundation Property Line Number SUMPS /R SEEPAGE PITS 1P Depth �� —Size r a -PropertyLine ice_ Foundation . 1 DO SU MP5 El Distance to nearest: Weil 1� E DISPOSAL PONDS ❑ I ' 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. 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,Califprlia." Contractors hiring or sub contracting signature certifies the following: "I certify that in the performance of the work for which this�permit.is issued, E=small employ persons subject to workman's compensa tion laws of California." 4 The applicant must call for all required inspections. Com lete drawing on reverse side. j Signed Title: f: i Date: FOR PARTME ONLY Application Accepted by Date ea 1�,/] ,.�•r,r..."'"".,_--`�� -: A Date ti -tl/�Cs��l~-----:-- Dby_ �*Pit-Pitiout-inspection-by'--- ate— Final Inspection Additional Comments: © Stk 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, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. INFO 6 + EH 13-24.(REV.1/85) >' �p EH 14-28 v- . n