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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. i ' U&JtOA) P O �TG1F4 Lot Size 213 Y Cent City Job Address PM s Owner's Name L,A M A Dow 61--Address Phone r, C '�r w ,24 Contractor � �' .. � Address -�,"= License Na, Phone TYPE OF WELL�PUM NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ y, t ,:,PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE I+� wFOUNOA ION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED."US_E r*TYPE OF`W' ELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑6pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private' ❑ Gravel Pack S ❑ Tracy Type of Casing f Specifications 1'1 Public �4 n Ocher Type of Grout i Irrigation i __Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done 17 Type of Pump'. H.P. -State Work Done _ Well De struction. ❑" Well Diameter #Seating Material Itop 50'1 11 Depth f Filler Material (Below 501 r TYPE OF SEPTIC WORX°—NEW INSTALLATION IT REPAIR/ADDITION I I DESTRUCTION f I (No septic system permitted if public sewer is 0 T 4 ! t ; available within 200 feet.) �- Installation will serve: Residence—Commercial_ Other ; Number of living units Numbei of-b^dtoom�s �• + A Characterrof soil to.a�depth of 3 feet: ''+,�`W'CJf`'°:�-- ' _ Water table depth rV 1 SEPTIC TANK �°! ❑ Type/}Mfg 9^"J _� It. R`,�"I Capar-.ity 00 Na. Compartments i PKG. TREATMENT PLT. ❑ t t- Method of Disposal }: 7istancto nearest: Well Foundation g Property Line i . LEACHIrNG LINE No.+& Length of tines 0 � 4 Total length/size d FILTER}BED ❑x 6istance to nearest: Well Foundation ( r�r Property Line SEEPAGE PITS 11 Depth Size t x 1 fJ Number r SUMPS L�Distance to nearest: Well�0� Foundation �o `- Property Line a2 DISPOSAL PONDS © hereby certify that I have prepared this application and-that the work will be done,in accofdance with San Joaquin county ordinances, state laws, and } rules and regulations of the San Joaquin Local Health District:, Home owner or licensed agen't'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�he work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant �must 'call for all required pections. Complete drawing on reverse side. Signed X ` ' _— Title:---�� /laO Date: w { DEPARTMENT USE ONLY 7— Application Accepted by, Da Date Area f Pit or Grout Inspection by Da a Final Inspect' by Date r r Additional Comments: ❑ Stk 1466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ApplicantReturn all copies-to: Enviro#mental HealihermitJ.Services 1601 E. Flazelton Ave.;-P.p.—Bax 2009,—Sik,,CA-9520.1: FEE AMOUNT DUE AMOUNT REMITTED,. ti f 'RECEIVED BY DATE PERMIT'NO. INFO • EH 14-26 IRE 1/85) ` ss 31�i� ss r