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4 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091.466-5181 1PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NOV,�_ (Complete in Triplicate) ,qN JQ 198 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the woklSAreft 06 T," plication is made in compliance with San-Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and�R � Ljoaquin Local Health District. R]1 Job Address % !�L/ -�Grd-Q-� City Lot Size PM Owner's Name A 1 T Address /'f ( %6 �f�`c«°Q- - Phone r s Contractor's Name License No. 2A6 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR K__ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES_ _ DISPOSAL FLD. PROP. LINE FOUNDATION� . .� — AGRICULTURE 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 Domestic/Private ❑ Gravel Pack. ❑ Tracy Type of Casing' Specifications I 11Public C1Other r C7Delta Depth of G out Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. I State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) C Installation will serve: Residence_ Commercial_ Other Number of"living units: -""N Number of bedrooms Character of soil to a depth of.3 feet: ! I Water table depth C1�1 SEPTIC TANK ; ❑ ,Type/Mfg. Capacity*,=�, *'� � � Na."Compartments 4 PKG. TREATMENT PLT. ❑ n7 Method of Disposal " ,,yry Distance to nearest: Well Foundation Property Line LEACHING LINE ❑°&No. & Leng[h of lines Total length/size " FILTER BED '❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line ... DISPOSAL PONDS ❑ 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 i rules and regulations of the San Joaquin Local Health District. 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."Contractors hiring or sub-contracting 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 applicant must call f II required inspections. Complete drawing on rev se side. Signed X-,k1 A Title: Date: J Ja FOR IDARTMENT USE ONLY �^ Application Accepted by ! 4 Data/ "J Area Pit or Grout Inspection by Date Final Inspection by ,r Date` Additional Comments: A ❑ Stk 465-6781 ❑ Lodi 369-3621- ❑ Manteca 823-7104 ❑ Tracy 8356385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE r. AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. + EH 13.24(REV.10/83) L7j ,1 g EH 14-28 - FFF------^^^`