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APPLICATION FOR PERMIT RAYNIEN 1 .,AN JOAQUIN LOCAL HEALTH DISTt._,T �^ .4►r:°^ - �; 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 JAN 0 5 ?999 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED lltr ry " '"EALI`H s-',,vlC�s dvIRONM (Complete in Triplicate) ENTAL yE,ti 1H etvisloN 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 i5--7S E. vl Ltd r 1ZQ ad City, np I Lot Size 7 aC re PM _ � 1i,,J� Owner's NameSDhN -TCLI��2 r'{r.�I 4ze(z ddressS0(rame.TC� C-,4- g5y5l Phone -cm ` I r Z3�loz rally Sr�Sccf �'G Den V se N'o. O�J9 Z� Phone 510��t41a '0`>'lQla Contractor I rol1f I Address 4d w TYPE OF WELL/PUMP: NEW WELL ❑ -WELL REPLACEMENT ❑ DESTRUCTION ❑ .. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER. 3ele ItJC- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS l jk INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing, ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications -) Public fl Other t7 Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I DESTRUCTION I I (No septic system permitted if public sewer is N,N available within 200 feet.) Installation will serve: Residence_ Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 11 A` LEACHING LINE ❑ No. & Length of lines Total lengthisize FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll 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 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 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 appZt for all required inspections. Complete drawing n reverse de. Signed � Title: Date: I FOR DEPARTMENT USE ONLY ll Application Accepted by - �,A6LcGh Date L J C l Area LO P Pit or Grout Inspectionb Date Final Inspection by `� �M�"'\ Date fI� I Additional Comments: 1 ❑ Stk 466-6781 ❑ di -3621 ❑ M4nteca 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 �jAMOO�UNNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED By DATE PERMIT NO. . EH 13.24 IREQ/.r 5r ,ov Z /• 0v 3c)SC) C) EH r4-29