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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE I ON AVE., STOCKTON, CA 1 Telephone (209) 466-6781 I 5 �, �q199 87 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -_ `---'- I {Complete in Triplicate! ENVIROMENTAL HEALTH - l3o-a�— rt�f3?- u1. `!`Z LLr.E _LY�.:�F :�_i art ��`�� EERRM T SERVICES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descry` . his 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. FOYm!�P.ro Eaa4afes �J /! 1 arroak5 >QP�x ' Joh Address �� h h C(rC� ty T a �� PM �q C-ity r+ [ L_jo.,t,_Size /+ Owner's Name I l i�'i .. l/`P-l� �� + Address PV &X I q l`f_ 4� k: :SYL Phone -/qz2 - Contractor fn nj n- S 605• Address 35215 I llt�, an,- e oCt License No. 2 �D 1 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK Il;'D' SEWER LINES DISPOSAL FLD./M'+ PROP. LINE -55.' 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL 'PROBLEM AREA CONSTRUCTION SPECIFICATIONS r! Cl ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation IfIr Dia. of Well Casing -C1' `f(DomesticJ Private )d Gravel Pack IN Tracy Type of Casing P ye, Specifications W ❑ Public ❑ Other ❑ Delta Depth of Grout Seal �� f Type of Grout .1 ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by d Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material {Below 501 ,. TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet) Installation will serve: Residence— Commercial Other # t 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 LEACHING LINE ❑ No. & Length of lines Total length/size , FILTER BED ❑ Distance to nearest: Well Foundation Property Line r , SEEPAGE PITS ❑ Depth ! Sizey L Number SUMPS ❑ 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."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." The applican ust call for all re 'ed inspections. Complete drawing oIn r verse side. Signed Title: ` /�[��TC�.[z.S Date: 'I F DEPARTMENT USE ONLY . { Application Accepted by Date `�J Area /7i i Pit or Grout Inspection by Date{ Final Inspection by Date •i Additional Comments: D � ) ❑ Stk 466-Ml ❑ Loi 369-3621 ❑ Manteca 823-7104 ❑ Tracy -835 6mi Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Y - 1 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO It + EH 13-24(REV.t/e 61 IN/�J� a.7 :J EH 144-28 !! r�