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1� 05 m I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT N O W ALL 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-67$1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED '!�-,L,f_', C�,X { w.L (Complete in Triplicate) tc_' 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 rF 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. 1 ,, Job Address3'3So� QST city�To«rd� got size ' G P �y ' PM Owner's Name ".Cft�2Y ./ESN /� Address 44 4,e SPhone Contractor_ ,SELF l Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ J PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK StftR LINESISPOSAL.FLD. PROP. LINE FOUNDATION AGRIC TUBE WELL OTHER WELL PITS/SUMPS INTENDED'USE TYPE OF WELL PROBLEM AREA NSTR TION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Packs ❑ Tracy pe of. sing Ir Specifications ❑ Public ❑ Other, ❑ Delta Depth of Gro Seal Type of Grout '"' ❑ Irrigation _...Approx. Depth ❑ Eastern Surface Seal Ins lied by Repair Work Done ❑ Type of Pump H.P. _ State Work Done Well Destruction 1:1 Well Diameter .',Sealing Material(top 501 Depth Filler Material-(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_,Commercial— Other. s Number of living units: Number of bedrooms s G Character of soil to a depth of 3 feet: �� t r Water table depth SEPTIC TANK ❑ Type/Mfg l CapacityNo. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal Distance to nearest: Well Foundation Y Property Line LEACHING LINE ❑ No. & Length of lines Total length/size F FILTER BED EJDistance to nearest: Well Foundation Property Line SEEPAGE PITS . ❑ Depth I Size Number SUMPS ❑ Distance tonearest: Well Foundation' Property Line DISPOSAL PONDS ❑ I j 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of•Califomia:"-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-- •+ tion laws of California." nt mu c Il for all required inspections. Complete drawing on r rse side.Sign;pi 4 Title: Date: �1�� R WR&RTMENT USE ONLY Application Accepted by Date_ L-5 _ Area 0 Pit or Grout Inspection by Dae Final Inspection by 1PQ_C ac ate 7. Additional Comments: &' ❑ Stk 466-6781 Cl odi .369-36211 ❑ Manteca 823-7104 ❑ Tracy B3fr6385 Applicant- Retum..all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE j AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. CASH +EH 1324(REV.t/85) 5t EH,14-25y .-p �ze � . � a Q•� 73