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n' 'e, r:, r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT. 1601 E. HAZEL T ON AVE., STOCKTON, CA - Telepho'he 52091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in-Triplicate) CLAY 16 19$9 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. 18&2 for well/pump and the R1�kes"and Regd6iiions'of.the LSa� Joaquin Local Health District. PL-i'd,llo SLRII/r�. $ � �• �s'3 -- r7�--o r Sr to Lot Size ? acr PM Job Address City 11ROP Owner's Name L+nlcai-4 %+ 01 _ Address lot 6 Phone 13e,y L,-s- r Contractor;;; I� "Address ,rglgres7efAF License No. 4$4288 Phone 2 0^6 z- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT tK DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ .DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES >f00' DISPOSAL FLD.>360 PROP. LINE >40` FOUNDATION ?J6 AGRICULTURE WELL >3or5 OTHER WELL >300 PITS/SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑;Open Bottom ❑ Manteca Dia. of Well Excavatr n Dia. of Well Casing �Domestic/Private ER-Gravel Pack El Tracy Type of Casing T•G' S +0 Specifications 17 Public R'Other ❑ Delta" Depfft of Grout Seal r Type of Grout jI k Irrigation µ _Approxi Depth I I Eastern - Surface Seal installed by if',P�Ld INC. l Repair Work Done ❑ Type of Pump H,P. State Work Done_ �l i Well Destruction ff Well Diameter Zrr Sealing Material Itop 50'1 Depth Filler Material (Below 50'1 - TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 !No septic system permitted if public sewer is rl'[h available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of livingunits: I� Number of bedrooms r` i Character of soil to a depth of 3'feet: Water table depth \v\ SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE" " =--D it No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑a . 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 5 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, I shall not employ any person in such runner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certi`fy that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compansa- i "tion laws of California." RIS The applicant must call for 'I required "nspections. Complete drawing oonnreverse side. Signed . .p Title: 7' .1 Y�Ebcr�G l S T Date: j FOPA T USE ONLY Application Accepted by Date rea �r 3 Pit or Grout Inspection by Date Final Inspection b Data Additional Comments:" ❑ Stk 466-6781 ❑ Codi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant,- Return all copies to: Environmental Health Permit/Services 1601 E.-Hazalton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMIT'NO. INFO EH 14-26 III ••