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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL"HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA f Telephone 1209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED „ (Complete in Triplicate)- Application is hereby made to the SanJoaquin 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 L✓ 1"q" r �Qi15 City�STx'1z Lot Size `t- PM w. Owner's Name Address a T Phone Contractor . i CO23-S JQ )Zho)16 Address 106 1B 45 73 License No. Phone TYPE OF WELL/PUMP: J. NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 4' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAR EST.:_.SEP.TIC_TANK, --SEWE_R LINES --°.DISPOSAL FLD.- PROP:-LINE*- - I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ^❑ Industrial I ElOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing E: Domestic/Private .❑ Gravel.Pack ❑ Tracy Type of CasingOSpecificati6ns ❑ Public ' © Other i t- ❑ Delta Depth of Grout Seal Type of Grout t ❑ Irrigation --LApprox. Depth ❑ Eastern Surface Seal Instailed,by +. 0pairlWork Done ❑ Type of Pump H.P. State.Work Done Well.Destruction ❑ Well Diameter Sealing Material Itop 501 } Depth "tFiller Material (Below 50') k TYPE OF SEPTIC WORK: NEW INSTALLATION ❑# REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is U ^a j. available within 200 feet.) Installation will'serve ResidencAt Commercial— Other .S � ^ ` a r Number of living,m'ts:� Number of bedrooms r Character of.soil to ea depth of 3 Water table depth SEPTIC TANK : Type/Mfg Capacity-42 0M No. Compartments PKG. TREATMENT PLT: ❑ f J Method of Disposal Yr Distance to nearest: Weil Foundation Property Line'0 LEACHING UNE y© No. & Length of lines f Total length/size f FILTER BED ''Q_-Distance to nearest: Well /rv-n Foundation s Property Line ..-f r1� `i.i SEEPAGE PITS', ~ �W Depth f Size .3 Number SUMPS, ' El Distance to.n_earest: Well Foundation Property Line DISPOSAL PONDS ❑ -ke " 1 I hereby certify that I have prepared thisapplication 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: 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 as16-become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that inFthe performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." 4} ' The applicant must call for all re ire 'nspect' ns. Complete drawing on reverse side,N Signed Title: �� - Date: l4-'l1' Y FOR DEPARTMENT USE ONLY-----I , Application Accepted by `; =� Date [5�v l�' 96 Area l i P i k . z 4 t . W . aDate Pit Grout Ins'action by bate ..�r� Final-lnspeotion byg, ,ems Additional Comments: t ❑ Stk 466-6781 ❑ Lodi-369:3621- +•^❑-Manteca-823=1104 ❑ Tracy 835-6313.5 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO �^AMOUNT DUE AMOUNT REMITTED CASH CK 4 RECEIVED BY DATE. PERMIT'NO. +£H t3-241REV.1/A5) L •' .: *`�� llvl%_�L-4 - bEH 14-25 , O l �