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APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT f .. 1601 E. HAZELION AVE., STOCKTON, CA Telephone 12091 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. t i A Job Address `� City �-- Lot Size ` I'��-' PM Owner's Name �� vV E-Tisw iFess -Ar�cvssL) Phone b c� s r Contractor Address - License No. Phone TYPE OF WELL/PUMP::, ' NEW WELL ❑ WELL REPLACEMENT ❑ r DESTRUCTION ❑ PUMP.INSTALLATION ❑ -SYSTEM REPAIR ❑ OTHER ❑ E DISTANCE TO NEAREST: SEPTIC.TANK SEWER LINES DISPOSAL FLO.—' PROP. LINE i ` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE } TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i .❑ Industrial ' '❑ Open Bottom -- ❑ Manteca - Dia. of WellExcavation Dia.'of Well"Casing ,r ❑-Domestic/Private'" ❑=Gravel Pack ❑ Tracy Type of Casing Specifications t l`I Public ❑;Other' F-1Delta Depth of Grout Seal 7, Type of Grout a -- I I I Irrigation -Approx. Depth l l Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ r Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material IBelow 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION [ REPAIR/ADDITION I I DESTRUCTION I t INo septic system permitted if public sewer is available within 200 feet.) d' k Installation'will serve: Residence A Commercial— Other r Number of living units: __t__ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK jType/Mfg Capacity No. Compartments i. PKG. TREATMENT PLT. ❑ _ ` Method of Dispolal f Distance to nearest: Well -..%ObJt-Foundation AS Property Line amu_ \\\ I I + LEACHING LINE No. & Length of lines — a 0 Total length/size—ipL 90r I FILTER BED ❑ Distance to nearest: Well Do "IF Foundation i` Property Line - I ' " SEEPAGE PITS I 1 Depth Size Number SUMPS Cl 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, stale laws, and r rules and regulations of the San Joaquin Local Health Di§trict. 1, Home owner or licensed agent's signature certifies the following: "l 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,1 shall employ persons subject to workman's compensa- tion laws of California." J f The applicant st call for all re u'ed inspections. Complete drawing on reverse side, Signed f Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by - 01, Date LA —Z'� _Sig__,Area Pit or Grout Inspection by " Date Final Inspection by Date _ I , Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 - i=3 Manteca 823-7104 ❑ Tracy 835-6385 Applicant-- Return all copiesfto:;Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE ,-'AMOUNT DUE AMOUNT REMITTED. CK rRECEIVEO BY DATE PERMIT•NO. INFO H +.EH 13-24 4REV.1/85) EH 14-ZB -. 96 ' 1 zo x