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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 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. 1 Job Address �,� Q2 A.vi L i el!r Lad, _ 75.-/4City 7 c Lot Size PM — Owner's Name �reyt° Pe,vA• y �TeIYy>t Address yx r/. G"_A.—i L rN a Phone Contractor SD Address T — �' $Lv �{—" License TYPE OF WELL/PUMP: NEW WELL 13WELL REPLACEMENT ❑ DESTRUCTION 11 I t PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNOATION AGRICULTURE WELL OTHER WELL PITS/SUMPS k' � INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ILl ❑Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing .. DomesticIPrivate O Gravel Pack ❑Tracy Type of Casing " — — Specifications F1 Public -----' T of Grout _ fl Other � F1Oelta: Depth of Grout Seal I Yt� Irrigation ---Approx. Depth LI Eastern Surface Seat Installed by �- — — Repair Work Done ❑ Type of Pump H. P. v`"''k'State Work Done ti Well Destruction D Well Diameter — Sealing Material trop 50',) ._ ; v 1 �� ' '-- Depth Filler Material (Below 50'1 — TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR /ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: 31 Residence % Commercial ^mer t Number of living units: Number of bedrooms 3 —J— d ✓ C4,0 Water table depth Character of soil to a depth of 3 feet: I SEPTIC TANK El Type/Mig� Capacity-._� No. Compartments +Method of Disposal _ PKG. TREATMENT PLT. Ll i }1 roperty Line Distance to nearest: Well Foundation �-F i LEACHING LINE FILTER BED SEEPAGE PITS X — 100 Total length/size 000e No. & Length of lines D Distance to nearest: Well /tVOt Foundation__.- !1 Property Line I i Depth _ _ Size Numbef _ — SUMPS L1 Distance to nearest: Well foundation i : Property Line_ DISPOSAL PONDS 0 _ [ G I hereby certify that I have prepared this application and that the work WA�1M-done in accordance with San Joaquin cou�y 8Minarices; state laws, and rules and regulations of the San Joaquin Local Health Di§trict. k. permit is issued, I shall not Home owner a licensed agent's signature candies the following: "I certify, that in the performance of the :work for which this pe 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 whi h this permit is issued] I sshall employ persons subject to workman's In mpensa tion laws of California." =- I I. c The applicant mu t call for all required inspections. Complete drawing on reverse side. ' fl r r'+ F TiI J Date: /d_I — 94.E _ Signed X itle: .� r 7Da �DEI$ARTMENT USE ONLY : 1 %Application Accepted byDate' Area Pit or Grout Inspection by Final Inspection by r � -- Date Additional Comments: C Jn _d y'T,�il yr rr y kd Z� C 4.", 6 _ 1 oil i e c� ❑ Stk 466-6781 D Lodi 369-3821 ❑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 r .. EH 19-24 (REV. 1 n EH 14-M FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED CASH BY DATE PERMIT No. INFO