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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (2091 466-6781 PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED (Complete in Triplicate) 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. . . AC Job Address /7- 74 City 4000f Lot Size 4 L PM r � !/jQ� SA I` Address w /�i PhoneS 68- 3 S 3 Owner's Name T .. _T �y�1 �� Contractor 4'' ��SS i AddresA rsA 1-77 License No3773$5 Phone, 3 T-Y7 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 L�0 '" FOUNDATION"" o-AGRICtJLTUFtE WELL- OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA " CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 'KDomestic/Private `Ld Gravel Pack . ❑ Tracy Type of Casiri gP VC Specifications 4 M Public n Other FIDelta Depth of Grout Seal /00 Type of Grout cc^&VT t 1 1 Irrigation L4,')-.-Approx. Depth`y�I I Eastern Surface Seal Installed by CO N r &Z-01L.. ` Repair Work Done 11Type of Pump �+ ...- H.P. �. State Work Done y J f Well Destruction ❑ Well Diameter 1 Sealing Material (top 501 Depth 1 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 ` RFPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is ■ a available within 200 feet) Installation will serve: Residence�i Commercial— Other Number of living units: Number of bedrooms k Character of soil to a depth of 3 feet:-:'"^ i Water table depth SEPTIC TANK t ❑.'Type/Mfg Capacity No. Compartments Cf PKG. TREATMENT,PLT. E]Y Method of Disposal Distance--to'nearest: Well Foundation Property Line n LEACHING—LINE-1 ❑ No. & I_ength of lines i .Total length/size FILTER BED ❑ Distance to nearest: Well' Foundation Property Line SEEPAGE PITS' l 1 Depth �� Size Number SUMPS �s' Ll Distanceto nearest: Well Foundation Property Line 0 DISPOSAL PONDS ❑ 5 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, ander"' rules and regulations of the San Joaquin Local Health Di%tfict. i 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, 1 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 `3 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 mup call for ons.all squired inspections. Complete drawing on reverse side. I I Signed X Title: Date: 3—�� r . R DEPARTMENT USE ONLY t Application Accepted by �4Date 3"�6'�� Area Pit or Grout Inspection by Date S Final Inspection by 't r �Datec?' + Additional Comments: I � ❑ 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 FEAMOUNT REMITE TED EIV—ED n]B_Y". DATE ATE P�E-_R+MrIT-,'NO. INFO MOUNT REC 6- EH 1 3'24 IREV,1/6 5) b37. EH 14-26 r I