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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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. Job Address _��7�., ,...N,. D J t7G .ENCity .".,4j:29t Lot Size PM c Owner's Name -Dee_ � &F,_,&4M 4AAdress Phone 4 79 Contractor/�//�17e//Yfi9N$ LIJ�ddress j2ZAQ L['J ��,1�1/P1,License No.�_Phone TYPE OF WELL/PUMP:' `-` NEW'INELL ❑ ' - WELL REPLACEMENT ❑-- "-DESTRUCTION ❑' PUMP INSTALLATION j$ REPA./x6iltD47STEM REPAIR Ll OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK. _ :SEWER LINES-. DISPOSAL- FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED-USE ---TYPE OF-WELL- -^-PROBLEM AREA -CONSTRUCTION SPECIFICATIONS^- — - -- ❑ Industrial _Open Bottom T El Manteca Dia. o Well Excavation Dia, of Well Casing ❑ Domestic/Private ItI❑ Gravel Pack ❑ Tracy Type bf Casing""" ^� Specifications Public f❑ Other ❑ Delta Depth of.Graut•Sea) Type of Grout ❑ Irrigation s ----Approx. Depth ❑ Eastern Surface'Seal Installed by ' Repair Work Done ❑ Type of Pump ZfV H.P. 7 IS �' State.Work Done 0_1J L L 'J`1�RBi Well Destruction ❑ ]Well Diameter Sealing Material (top 50'1 4J!,-,0r.At 5XVA_ L- ._tiFu�2 .Z"lT� _241,,Lw, J . _ l Depth Filler Material-(below 501 \ \ TYPE OF SEPTIC WORK: NEW INSTALLATION D.-REPAIR/ADDITION ❑ DESTRUCTION ❑)1No septic system permitted if public sewer is �✓ _ l 1 available within 200 feet.) Installatioh will serve: Residence_ Commercialk' Other Number of living units: Number of.bed rooms Character of soil to a depth of 3 feet: %� - r Water table depth SEPTIC TANK !a Type/Mfg ! r'CaP40. F�? #No. Compartments PKG. TREATMENT PLT. ❑ .` } }Method of Disposal Distance to nearest: Well Foundation Prope!!ltity Line LEACHING LINE ❑ No. & Length of lines I _Total length/siie FILTER BED ❑ Distance to nearest: Well Foundation � Property Line SEEPAGE PITS ❑ Depth R p ,Size E Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 1 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: "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 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 mus al for all pequired inspections. Complete drawing on r erse ide. ^" Signed X Title: Dale: � F DEPARTMENT USE ONLY -�i'6`- 'ter 'I ~-f/ •; �~ Application Accepted by Date AYea u Pit or Grout Inspection Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 1009, Stk., CA 95201 7 FEE INF{] AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY / DATE PERMIT'NO. + EH 13.24 SREV.1/95} EH 1426 7 �� r