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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL. HEALTH DISTRICT 1601 E. HAZE; TON 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. f- ll a Job Address //� & - �- ;�,� '��Li _ City i �7r�� } Size PM f Owner's Name�r_fes)Z J Address _f/��JSIJ �3- � ��( -. / Phone C2,3!2 "ntiaot ' lk' � Ont, pp License No. '7J.5�Phone TYPE OF WELL/PUMP; NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION*15' SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES J100 Y DISPOSAL FLD. PROP. LINE Zj2d t FOUNDATION r AGRICULTURE WELI_k2cInD OTHER WELL QPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Indus pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C1�Uomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing— �Q e �.� w Specifications I'1 Public ❑l Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation lJ"L,Approx.'De th I Eastern Surface Seal Installed by Repair Work Done M'—Type of Pump�i r H,P. - ._ State Work Done Well Destruction ❑ Well Diameter , Sealing Material (top 501 - t Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION t-I DESTRUCTION I I (No septic system permitted if public sewer is r ` xf4. available within 200 feet.) Q ti Installation will serve:M Residence Cbmmercial__Other;" "' -�--- ---_-= S .,r \� Number of living units: Number of bedrooms , Character of soil to a depth of 3 feet,I Water table depth r SEPTIC TANK ❑ Type/Mfg; - f`' Capacity No. Compartments PKG. TREATMENT PLT. ❑ 4./ `' �' r' �... � Method of Disposal 1j { v� Distance to nearest: Well Foundation Property Line �J t ; LEACHING LINE ❑ No.`A Length.of,lines -"`- Total length/size FILTER BED ❑ 'Distan'ce to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth ;f r Size Number \• SUMPS L Distancenearest: Well r Foundation Property Line ° DISPOSAL PONDS ;Q i ''" ""� " Tr-- •`�- F ,i } I hereby certify that I have prepared`tfis 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: "1 certify that in-the performance of the work for which this permit is issued, I shall not r 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- I: tion laws of Califorftial'- �� r - V °.� The applicantm st call for all requiraq inspect d 5F Com dra g oLo erse side. Signed X Title: Date: O OR DEPARTMENT USE ONLY r r p Application Accepted by Date OL) Area_ � t Pit or Grout Inspection by Date3 26 Final Inspection by Date O Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmjj ental Health Permit/$ervices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ' f FEE AMOUNT DUE AMOUNT REMITTED INFO J(� CA/SH RECEIVED BY DATE �i PERMIT'NO. + EH'13211REV.5iH51 '� �4 !`�V% rNl ,#3p6� 1 �.�_96? Ir�7 EH tase ��YII "'��HYY"' "V L� 0 Q t