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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 SEP I 1 1999 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENV IRON VEN,TALHEA 1h (Complete in Triplicate) 0CRMI- 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 veli!pump and the Rules and Regulations of the San Joaquin Local Health District. I Job Address loos City. ize PM Owner's NamJ _ &_!X. LA Lt�A r. fC✓DY Av"i _ Phone —V—f No.��Phoneq, TYPE OF WELL/PUMP: NEW WEL ❑ WELL REPLACEMFNT ❑ DESTRUCTION ❑ PUMP INSTALLATION, SYSTEM REPAIR .7 OTHER O DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ ❑ Industrial ❑ Open Bottom a Manteca Dia. of Well Excavation pia. of Well Casing `!306 mestie/Private ❑ Gravel Pack D Tracy Type of Casing Specifications ('1 Public Cl Other 17. Delta Depth of Grout Seal _ Typo of Grout I I Irrigation —Approx. Depth astern urface Seat Installed by. Repair Work Done : 1 Type of Pump /t. H.P_ State Work Done Well Destruction Ll Well Diameter Sealing Material (tap 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I ! DESTRUCTION 1 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence__. Commercial_ Other Number of living units: Number of bedrooms r ?I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg _ Capacity No. Compartments _ p(Z h PKG. TREATMENT PLT. ❑ Method of Disposal __- Distance to nearest: Well _ Foundation Property Line LEACHING LINE LI No. & Length of lines Total length/size FILTER BED Q Distance to nearest: Well _ Foundation Property Line SEEPAGE PITS ( I Depth _. --Size Number 5 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 Di3trict. 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 applican 1% callr a r qt fired i spectiwts. Complete drawing on orse � ^ Q171 Signed cyjajg�lL3�� Titl _ _ Date: (JJJ OR DEPARTMENT USE ONL Q Application Accepted by Date ! -IryArea Pit or Grout Inspection by ate Final Inspection by r Data ' Additional Comments: _ n Stk 466-6781 0 Lodi 369-3621 Ll Manteca 823-7104 ❑ Tracy 8356385~ 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 CK RECEIVED BY INFO CASH DATE PERMIT'NO. . EH 13-74 INEV. / r EH 1M2d f