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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL"HEALTH DISTRICT " 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 € PERMIT EXPIRES TYEAR 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 1 Local Health District. Job Address _ 7 Y,H V ' (- /.�� /�ti� City c Lot Size � �� PM Owner's Name — _ y_1AAy Address Phone f ;Contractory" m Y Address_ .f�'GL License No. 307X Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT, ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC_TANK 1 SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION ; L .AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE 4 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I, ❑ Industrial l c O Open"Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing Y ❑ Domestic/Private, ❑ Gr vel Pack ❑ Tracy Type of Casing Specifications t l i Public fJ Other i1 Delta Depth of Grout Seal Type of Grout 11 Irrigation !---Approx. Depth { I Eastern Surface Seal Installed by _ Repair Work Done L1 Type—cif—Pump f I H.P. State Work Done_ n .Well Destruction ❑ Well Diameter r Sealing Material (top 50') l _ - Depth---- t- Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION f I' REPAIR/ADDITION f DESTRUCTION I I (No septic system permitted if public sewer is available within 200.feet.) t Installation will serve: Residence Commercial__ Other NO'mber of living.units: __L_ Number of bedrooms Character of soil to a depth of 3 feet: 01 t1 Water table depth ! SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 1 I 7 Distance to nearest: Well Foundation Property Line LEACHING LILAC w ..� No. & Length of lines � '7CSr „Total length/size t FILTER BED ❑ Distance to nearest: Well Founldation__30_' Property Line d f I, SEEPAGE PITS l Depth Q Size _�2 t1 f Number SUMPS Ll Distance to nearest: Well Foundation , Property Line DISPOSAL PONDS ❑ 1 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 I rules and regulations of the San Joaquin Local Health District. p r4 Home owner br 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.” Contractors 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." l The appficanf must call for all required inspections. Complete drawing on reverse side. Signed X Title: ' t Date: a FOR DEPARTMENT USE ONLY s Application Accepted by „ ,.__. Date Area l` I P y_, n !/�i7r .1� Date 64 or Grout inspection by Date Final Ins action b 7 # r' Jr Additional Comments: t ❑ Stk 466-6781n----•0 Lodi 369.3621—El""Manteca-823=7104— h-Tracy4 35-6385 -- -------_w �• �— ti..� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 '. of - 5 'a-'a• � FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. +.EH 13-24(REV.1i 85) 70 00 70 0 0 � f 5 EH 14-28 R-3 , 52� {