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.r .. APPLICATION FOR PERMIT ,m SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES„i YEAR FROM DATE ISSUED (Complete in Triplicate) Application is horeby 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 Districts. Job Address / 7 M ejooUl all r\ CT, I City CeA' % Lot Size_�( �� -- PM Owner's Name �^ f hi r AddressAMR7 � ►Z P�jj Phone � — 'z Contractor Address 7 f4/1S'e �r License No. S`�0Ory Phone 7 ��?� TYPE OF WELL/PUMP: NEW WELL- WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION (Y SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 10—.F SEWER LINES 10 t t-_ DISPOSAL FLD. PROP. LINE { FOUNDATION Sk f AGRICULTURE WELL _ OTHER WELL PITS/SUMPS y -INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS •" ❑ Industrial- LKOpen Bottom 171Manteca Dia. of Well Excavation - Dia. of Well Casing ($rpomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing lie 0 Specifications C'7 Public n Other Cl Delta Depth of Grout Seal 11,90 Type of Grout �f I } Irrigation 221a_�Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump %3005 H•P• f State Work Done Well Destruction ❑ Well'Diameter Sealing Material (top 501 Depth. ! Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l 1 DESTRUCTION I I (No'septic system permitted if public sewer is q 1 t available within 200 feet.! Installation will serve: Residence Commercial f Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: '• T Water table depth V' f r SEPTIC TANK ❑ Type/Mfg 3 Capacity No:Compartments PKG.,TREATMENT PLT. ❑ ' f Method of Disposal n } Distance to nearest: Well Foundation Property Line _ �J LEACHING LINE ❑' No.• ength of lines I Total length/size'-FILTER BED ❑ Distance to nearest: Well Foundation • Property Line n 1 SEEPAGE PITS t Ir Depth; Size "` _ Number (� SUMPS Ll Distance to nearest: Well Foundation Property Line T 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, statelaws, and rules and regulations of the San Joaquin Local Health Diltrict. : v. Home owner or licensed agent's signature certifies the following: " certify that in the performance of the work for which this permit is issued, 1 shall 1 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 the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California," The applicant must c I for all req u ed.ins ctions. Complete drawing on reverse side. Signed X 1 Title: _ Date: i y�� FOR DEPARTMENT USE ONLY k2l Application Accepted by Date Area `rJ Pit or Grout Inspection by Date !'g2A-�4 Final Inspection by Date Additional Comments: ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMITNO. INFO +.EH13-241REV.1/85) EH 14-28 _ �.- kq-ate