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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone Q091 466-6781 I I PERMIT EXPIRES TY EAR 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 Yav Z494 9 UZ49:y_Z_ Cityof Size PM t f i Owner's Name jC _ _.Q RICWI"dress �6 ,tr 'Phone Contractor �dd. �U�1! Address 1_icense No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPL CEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYST REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION A ICULTURE�WELL OTHER WELL PITS/SUMPS INTENDED USE _ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LJIndustrial! ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing EJ Domestic;Private L] Gravel Pack ❑ Tracy r Type of Casing_ asing Specifications M Public L1 Other Cl Delta Depth of Grout Seal Type of Grout t 1 1 IrrigIation --Approx. Depth i I Eastern Surface Seal Installed by s _ e -Repair Work'Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material atop 501 I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION.(1 REPAIR/ADDITION l I DESTRUCTIO No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK EJType/Mfg '; 3 al 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:3 L Well Foundation Property Line SEEPAGE PITS 1-1 Depth ' Size Number SUMPS L Distance"to"ridarest: Well Foundation Property Line I 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\ �3 rules and regulations of the San Joaquin Local Health District. I I �^� Home owner,,or licensed agent's signature certifies the fallowing: "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 compe`nsafion 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." ! The applicant must ca` for al equir ' spections Complete drawing on reverse side. f Signed X s =.Title:�rfJ t Date: FOR DEPARTMENT USE ONLY Application Accepted by Date a' Area y a.t Pit or Grout'Inspection by Date Final lnsp,$ctioniby Dat 71 Additional Comments: E I _ D Stk 466;6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant . Return all copies to: Environmental Heafth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT-AMOUNT -^'--�--AMOUNT'REMIT`rED' " CASA RECEIVED'BY �" DATE""" "PERMIT`NO _— EEE_ �w SCK . .. H + EH 13.24IREV.1/85) EH 14-26 / l