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I' i? APPLICATION FOR PERMIT 1 I SAN JOAQUIN LOCAL HEALTH DISTRICT �. 1601 E. HAZE T ON AVE., STOCKTON, CA ,j Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ' _'k 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. N' Job Address 7a �A'YYl Ste✓ /��.� fi. "-� City y cl, Lat Size PM Owner's Name--x. i` A16- A �S Phone Contractor Address . (_. Z License No. Phone TYPE OF WELL/PUMP: r NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION Ll SYSTEM REPAIR EIOTHER ❑ i 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 r p ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public �-.,- (Dther_=�_ -I jDelta-6�Depth-of Grout Seal ,':.•Type-of-Grout-__ ❑ Irrigation ---Approx. Depth _❑ Eastern Surface Seal Installed by Repair Work Done 1:1Type of Pump T S. H.P. State Work Done k Well Destruction Well Diame et r Sealing Material (top 50'I m r- , —J Depth Filler Material [Below 501 } 6 3 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r available within 200 feet.) k" Installation will serve: Residence_ Commercial_ Other Number of living units: t 11 Number of bedrooms 6L i Character of soil to a depth of 3 feet: ' !a Water table depth SEPTIC TANK Il ❑ Type/Mfg +'Capacity No. Compartments " i PKG. TREATMENT PLT. ❑ Method of Disposal t 'Distance to nearest: Well Foundation Property Line , LEACHING LINE ' ❑ Nol'& Length of lines k U I 9 Total length/size 1 # FILTER BED ¢❑ Distance to nearest:_ Well- ,-.Eoundation_ . ,Property.Line. �„Te # li. SEEPAGE PITS ❑ Depth Size Number 9 f SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ k ,3 j 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 applicant must cal or all required in"'ooTetedrawing on reverse side. Signed' _ Title: (3 Wtol Date: ► g� FOR DEPARTMENT-USE ONLY Date Application Accepted by / Area / Pit or Grout Inspection by d ' s �� - ate Final Inspection by r'�`�'�' Date II Additional Comments: r 100/ ❑ Stk 466-6781 O Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Retbm all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 it FEE INFO AMOUNT DUE AMOUNT REMITTED CA in , RECEIVED BY DATE PERMIT'N0. i +EH13-24 Ill 1/85) $ EH 14-26 s / i