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R f't APPLICATION FOR PERMIT �J t SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE T ON AVE., STOCKTON, CA I Telephone (209) 466-6781 N 0 ,, y / PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 � _ (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 Joaquiri County Ordinance No. 549 for sewage or No. 1862 for wellipump and the Rules and Regulations of the San Joaquin Local Health District. 1 Q E Job Address r Z �7�7 � city 61M Lot Size *7SWO PM 2. , Owner's Name �� ` Address vJ• 7 Phone Contractor � Address Licen No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ —DESTRUCT10N:❑.__� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER.❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. � PROP. LINE I FOUNDATION AGRICULTURE,WELL OTHER WELL_!___FITS/SUMPS INTENDED USE TYPE_OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSn \ } ❑ Industrial ❑ Open Bottom LJ Manteca Dia. of Well Excavation Dia. of Well Casing v r - ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r {i Public ❑ Other F1 Delta Depth of Grout Seal i " ""` Type of Grout . I Irrigation --Approx. Depth �.I I Eastern Surface Seal Installed by r Y - a Repair Work Done ❑ Type of Pump 1 H.P. State Work Done # Well Destruction El Well Diameter Sealing Material (top 50'1 1 Depth Filler Material (Below 50'IT TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTIONXI INo septic system permitted if public sewer is ravailable within 200 feet. Installation will serve: Residence ;Commercial Other ' Number of living units: Number of bedrooms p Character of soil to a depth of 3 feet-. + �^ ? Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ' Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS !'l Depth; -Size;= � _� ti ; �`"' Number \ SUMPS ❑ Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ I I 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 rules and regulations of the San Joaquin Local Health District. s Home owner or licensed agent's signature certifies the following: 1 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 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 appli nt must call f r all re puire inspections. Complete drawing on reverse side. Signed 1C C3.""�'� w `� _— Title: C)OVIklo— Date: VZ—'1'9 R DEPARTMENT USE ONLY C r-r, r a Date i �/—97 Are I Application Accepted by i Pit or Grout Inspection by Date /� Final Inspection by Date Additional Comments: 17,517 �" ' ��' ❑ Stk 466-6781 ❑ Lod 369-3621 ❑ Manteca 1123-7164 ❑ Tracy 835-6385 Applicant - Return all copies to: Ernrironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520111 71ctJ�iyt, 1 3 1ze FEE AMOUNT DUE A OUNT REMITTED K RECEIVED BY DATE PERMIT INFO + EH 13-24(RFV.t i N 57 EH 10-28 35.0 8 Er7— �zr,