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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA E Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r 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. I i. . , .I ,, V Job Address City Lot Size PM I ,p _ Owner's Name T� NlA f U/.C� ? Address 7 Phone Contractor s+ Address nr�� liC»�� icene No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR,7 OTHER ❑ Q DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL C PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Pia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Public ❑ Other ❑ Delta Depth of Grout Seal ` Type of Grout I ❑ Irrigation --Approx. Depth ❑ Eastern Surf 'Seal-Installed-by---- t { Repair Work Done El_-Type of Pump� g�H.P. Z St to eork Ddne' r Well Destructi6n—'D Well Diameter Sealing Material (top 50'} aZ73Zy'.V. ' r, .-Dep� Filler Material-(Below 501 IKE Vt 9Q kE TYPPOF SEPTIC'WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is / ;available within 200 feet.) Installaticin will se a Residerice�f Commercial_ Other a IA. -i Cr � Number.of livmg� nits: i�"` Number of bedrooms ` r �.� f--- ! t Character of soil.to a depth'of 3.feet:, 1 ' Water table depth �. \ SEP�IC TAN\ Al ❑ Typ;/Mfg Capacity No. Compartments PKG. TREATMENT;PLT. ❑ CV iv Method of Disposal Distance to nearest: Well Foundation _ Property Line LEACHING LINE ❑ No. Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line t i SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Prc4rrty Line DISPOSAL PONDS ❑ 1 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. f 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 manner as to become subject to workman's compensation laws of California."tContractor'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." t The applicant r requi ctions. Complete drawing o eve /side. s r Signed '� Title: _ �/ {. Date: FOR DEPARTMENT,USE`O+NLY r i �f �/—O Application Accepted by � � �� { Date 5 r"c�t� x � Area rar/ Pit or Grout Inspection by Date--!'Final lnsi.ection by i A L Dat14L_1_1 1 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 a❑ Tracy, 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 A FEE F INFO AMOUNT�DUE � AMOUNT REMITTED CK— y+ RECEIVED—BY DATE iPERMIT'NO. EH 13-24(REV.1/65] f — / f EH 1126 0 ^rU