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APPLICATION'-F0191 PERMIT SAN JOAO.UIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.; STOCKTON, CA Dec Telephone (209) 466-6781SAN `51984 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I � N {Complete in Triplicate) W ��I l ZOCq .h ed" Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein describ t ition 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 then Joaquin Local Health District. Q I Job Address QCO% f i 1 1 City �'�� Lot Size PM �j n }�;fir, Owner's Name r�7 ( V C'l� /�1� Address S )''l Phone �` 7S_ Contractor's Names 1 f E+ License No. ]�1 Phone � �� iTYPE OF WELL/PUMP: NEW WELL ❑ 'I _ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION'❑ SYSTEM REPAIR 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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 ' Domestic/Private ❑ Gravel Pack . ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other t, �X1 Delta_ _ Depth of Grout Seal Type of Grout F ❑ Irrigation -.Approx. Depth .❑ Eastern Surface Seal Installed by Repair Work Done A Type of Pump)��'�- ,� H.P. 15 _ State Work_Done 'U9 Well Destruction ❑ Well Diameter -�. -Sealing Material (top 501 '� J Depth Filler Material (Below 50') �] TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR'/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is C71 t" _a x < J; available within 200 feet.) Installation will serve: Residence_ Commercial_-Other Number of living units:_ _timber of bedrooms I Character of soil to a depth of 3 feet: Water table depth i SEPTIC+TANK r �❑ Type/Mfg. Capacity No. Compartments PKG. TREATIIIIENTPLT.�C1-,= `` r t -" t 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 SEEPAGE PITS CI Depth Size Number SUMPS ❑ Distance to nearest: t Well \Foundation c Property Line DISPOSAL PONDS,n ❑ I hereby certify that I h ave prepared fFU application Ad'that the wi ork will be4done'ri-&ccordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local'Health District., •, n _ 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 Calffornia."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 Californiii:" -- :'. The applicanTANt call for all re d i' ctions. Complete drawing on re ve i w Signed Title: I Date: C2 t,Y} FOR DEPARTMENT USE ONLY 06 Application Accepted by Date ( 5 Area Pit or Grout Inspection by Date Final Inspection by Datef Additional Comments: ❑ Stk 4664781 ❑ Lodi 369-3621 anteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environments ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"N0. INFO CASH + EH 13.24(REV. 10/83) .i ` Q[� 1ZZr � 4_1 S S� EH 1428 'moi