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J-1 APPLICATION FOR PERMIT" SAN JOAQUIN LOCAL HEALTH DISTRICT / 1601 E. HAZELTON AVE., STOCKTON, CA AMOUNT DUE Telephone (209) 466-6781 C CASK{ S PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE PERt.117*NO. (Complete in Triplicate) d d f�`' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein &-scribed. 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. Job Address j2 Job , • 2 /1C Lot Size PM Owner's $% Name of I 0 him e- 5 HO U- 96-t Address 2!14 L� ek 514 ! I r- '" ' , Phone Contractor's Name ,J C C 0'0 S T IA -5- License No. -9 3014 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ _ �- PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O r` } DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION --AGRICULTURE WELL OTHER WELL -• PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing r ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (� ❑ Public ❑ Other ❑ Delta Depth of Grout Seal T ^-� - ype of Grout O Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H, P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will serve: Residence _ Commercial — Other available within 200 feet.) Number of living units; Number of bedrooms Character of soil to a depth of 3 feet: Water table depth" SEPTIC TANK AT Type/Mfg FeZor jiti 1r'S !!y rapacity C� No. Compartments PKG. TREf}TMENT PLT. ❑ Method of Disposal Distance to nearest: Well /00 4- Foundation /6 Property Line7E LEACHING LINE 5g� No. & Length of lines _�2 Total length/size 1!�7 O FILTER BED ❑ Distance to nearest: Well/00 I' Foundation ZZ' 7` Property Line SEEPAGE PITS A Depth ize _.730, 9c` 29 Number 2- SUMPS ElDistance to nearest: Wellj_-Z-_,�_ Foundation AQ I{ 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 District. Home owner or licensed agent's signature certifies the following:l`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 subcontracting 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 applica ust call or required in�sleerawingon reverse side. Si ned `�Cg Title: �,�rf'SS n .- o ^�� Data; FOR DEPARTMENT USE ONLY Application Accepted by Date - '� Area .e Pit gr Grout Inspection by Date final Inspection by rf Date Additional Comments: ❑ Stk 456-6781 Lodi 369 -Ml ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all opi to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2", Stk., CA 55201 + EH 1324 (FEY. 10/83 EH 1428 FEE INFO AMOUNT DUE AMOUNT REMITTED C CASK{ S RECEIVED BY DATE PERt.117*NO. d d f�`'