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k APPLICATION FOR PERMIT I 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) Application is heieby 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. , i r� Job Address 112*� lk frtS- City Lot Size PM -- i fI f � 1 fl I Owner's Name _ f,;�A1• Address 1 _ Phone Contractors 0- cf- Address •0 License No? Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 CONSTRUCTIO El Industrial L1 Open Bottom ❑ Manteca Di ell Excavation Dia. of Well Casing Pa ❑ Domestic/Private ❑ Gravel ck ❑Tracy Type of Casing Specifications F] Public ❑ Other to Depth of Grout Seal Type of Grout I ] Irrigation —.-Approx. Dep l I Eastern Surface Seel Installed by - Repair Work Done Ll Type of Pum H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 ! Depth r Filler Material (Below 5011 20 TYPE OF SEPTIC WORK: NEW INSTALLATIflN•1 l REPAIRIADDITION l ] DESTRUCTiO i INo septic system permitted if public sewer is + (� l EDIT available within 200 feet.] V Installation will serve: Residence! -Commercial — Other 1i Number of living units: Number of bedrooms k ' i Character of soil to a depth of 3 feet: Water table depth f{ SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ f Method of Disposal e Distance to nearest: Well r Foundation i Property Line ! LEACHING LINE ❑ No. & Lengthof lines Total length/size FILTER BED ❑ Distance"to nearest: . Well Foundation Property Line SEEPAGE PITS I I Depth, Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ :. --•- ------� __ f ; i hereby certify that I have prepared this application and that the work will be done in accordance wi[Fi-San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin Local Health District. Home owner or kicens agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, k shall not`` employ any r in h manner as to became subject to workman's compensation laws of California." Contractors hiring or sub contracting signaturel certifies the I certify that in the performance of the work for which this p�it is issued, I shall employ persons subject to workman's compensa- tion laws of a r ' The applican all all re uired inspections. Complete drawing on reverse side. F . Signed X Title:t f u lle'r _ Date: 1 12-k7 Y 4 FOR DEPARTMENT USE ONLY /13 Application Accepted by Date �Y Area Dat Pit or Grout Inspection bate _ Fi al Inspec�Jw y ` r t Additional Comments: ❑ Stk 466-6781 Ll Lodl, -3621 ❑ Manteca 623-7104 ❑ Tracy 635-6M5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT NO. QL`� INFO + j ( ��++ f ^�/ 4* EH 13-241REV.1/855 �� I1"2^97 EM 14-26 yU � +