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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Job Address (‘ (3 -7 41 Jhop—nia-y) Cit-crhall Lot Size /4 77 pm 4-6 Owner's Name •7 "15.776Ltike-Address 3/' "116 s i S/DeidenCISIX)7 hone Contra c tor 1 Address License No. Phone TYPE OF WELL/PUMP: _ NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION 0 PUMP INSTALLATION Li SYSTEM REPAIR U OTHER Li DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 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. INTENDED USE Industrial Domestic/ Private Ti Public I Irrigation Repair Work Done L.3 Well Destruction 0 TYPE OF WELL . 0 Open Bottom 0 Gravel Pack Cl Other I _..Approx, Depth Type of Pump Well Diameter Depth CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation Dia. of Well Casing Type of Casing Specifications C:b Depth of Grout Seal Type of Grout Surface Seal Installed by Ci H.P. State Work Done Sealing Material Material !top 50') Filler Material IBelow 50') PROBLEM AREA n Manteca 0 Tracy Ti Delta I Eastern TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION I DESTRUCTION : I (No septic system permitted it public sewer is Installation will serve: Residence „X Commercial Other Number of living units: I Numb er of bedrooms ")-3 Character of soil to a depth of 3 feet! SEPTIC TANK - AC Type Mfg PKG. TREATMENT PLT. 0 p Catitrn t 45r Distance to nearest: Well LEACHING LINE FILTEFI BED Nr No. & Length of lines Total length/size slier? 27c) 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I Depth 1 Size Number SUMPS Ll Distance to nearest: Well Foundation 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 signatu-re 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." ~4. The applicant st call for all requ. d inspections. Complete drawing on reverse side. Signed Title: Date: -3 ation Accepted by cey&FOR DEPARTMENT USE ONLY Applic Date 3* Area Area 7.--e-79015721--.19PDate Pit or Grout Inspection by Date Final Inspection by Additional Comments: available within 200 feet.) Water table depth* 1 No. Compartments Capacity L Cern chz..tcL. Prod acTS Foundation Method of Disposal /ea.a, Property Line Property Line Ti Stk 466-6781 Cl Lodi 369-3621 Cl Manteca 823-7104 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 irfft„if EN 13.24 fREV. 1 ,K EH 14-26 FEE INFO AMOUNT DUE ....ez, AMOUNT REMITTED CK i CASH RECEIVED BY DATE PERMIT NO. --,,25 , -09 C,es- a 9--.ZP n-A6 151 10 t cr-o —