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b APPLICATION FOR PERMIT " SAN JOAQUIN LOCAL HEALTH DISTRICT F 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ap 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 �� _�u�� .. G . K-t� � City_ Lot Size J0 L PM Owner's Name Address �F-yc. ��0� _ Phone Contractor's Name ALicense No. 5�a 13 Phone TYPE OF WELL/PUMP: NEW WEI L ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 7 S r DISPOSAL FLD. ' PROP. LINE _2 FOUNDATION Q_ 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 1) Tracy Type of Casing .02 a �'T pecitications Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. S State Work Done A.1 iscmJ F>u> 0,7v Well Destruction ❑ Well Diameter 28" Sealing Material atop 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIPN ❑ Mo septic system permitted if public sewer is available within 200 feet.) i Installation will serve: Residence_ Commercial Other j k Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size ! FILTER BED ❑ Distance to nearest: Well Foundation Property Line ,l SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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, 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." Thea licant� gt_call for all require inspections. Complete drawing on reverse side. ��:—,. . _ Signed X Al Title: l&50c. ei ILlt_ r_,2rA Date: 4 FOR EPARTMENT USE ONLY Application Accepted by av Date! f �3 Area Pit or Grout Inspection by _ Date Final Inspectiorgeby4'6 Date I_ .r Additional Comments: "" ;� !z - „__..._.,_..__. 21w ❑ Stk 466-6781 ❑ Lodi 369-3 1l+ ❑ Manteca 841-7140 ❑ Tracy 835-6385 e Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA.S5201FEE , INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT"NO. EH ,y� + EH 1428 13-24 hS'�1J-S0/83} r J ♦. C� LOT -7 S7 E I