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Y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTR 1 1601 E. HAZETON AVE., STOCKTON, 11�j`d +d 209 466-6781 ��mm�� Telephone { i � `.PERMIT EXPIRES TYEAR FROM DATE ISSUE®(; p 1989 § (Complete in Triplicate) ' ENVIRONMENTAL , EAI_�H Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instalmw 'Fi ed. This application is E made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and RegOationsoi the San Joaquin Local Health District. ] _ Job Address Cri�t,�� 0 City Lot Size, PM Owner's NameF _ _ 7 346 f- Address J c (0 3 (JR 14ER 4 Phone i •r / �� p Contractor 6?p S 2 pip f k;c Address/ M 2 License No. Phone 3 / TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION JK SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 4 INTENDED USE_ TYPE OF WELL._ PROBLEM AREA ,CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing Q1%Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (I Public Cl Other C f Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth 11 Eastern Surface Seal Installed by tltl Repair Work Done ❑ Type of Pump,JSIL,I H.P. I State Work DonaMS&L L A19L.) N Well Destruction ❑ Well Diameter Sealing Material (top W1 N , Depth Filler Material (Below 501 _ (� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.i Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: f Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 6: Distance to nearest: Well Foundation Property Line 0 i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size 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 Di$trict. J ""�T '�' '� " "" — 4 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 I 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." 1, The applicant must call for all required inspections. Complete drawing on reverse side. Signed 0 AA * Title: Date: �� `Sr `07 F EPARTMENT USE QePILY Application Accepted by Date Area Pit or Grout Inspection by D to Final Inspection by -�1� �+z_�� Date I �' h Additional Comments: C1 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEECK 4 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE p� PERMIT"NO. +"EH13.241REV.1in51 EH 1428 J