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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Vi Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 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: Ii til4dcmort Job Address ;Z Y_4-1 ,f�i�Acfi'l�l City Lot Size 167/4GYCr PM Jj�y iy �/rte , Owner's Name Address Phone t ?v Contractor's Name XdVr/4!!HY ' %P40' License No. yj�,-epv Phone -42X TYPE OF WELL/PUMP: NEW WELL ❑ WELL,REPLACEMENT ❑ DESTRUCTION ❑ j PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK `SEINER-LINES"" —_ ""t DISPOSAL FLD. PROP. LINE E FOUNDATION AGRICULTURE WELL r OTHER WELL—._PITS/SUMPS iCCC I ----INTENDED USE-- TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ? ❑ Domestic/Private t❑ Gravel Pack E] Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by 4 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material IBelow 501 TYPE OF,SEPTIC WORK: NEW INSTALLATION X REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is i 1 available within 200 feet.) i I Installation will'serve: Re siden .ceCommercial— Ofhe� "� ~ Number of living units: Z Number of bedrooms Character of soil to a depth of 3 feet: S24YDd` hww `?_ 4 Water table depth i FSEPTiC TANK Y :Type/.MfgB r4f7' Capacity 100 No. Compartments WG. TREATMENT PLT. Cl I Method of Disposal f Distance to nearest: well Foundation -` a Property Line LEACHING LINE Jj5 No. & Length of lines s'0 Total length/size E6v 4 FILTER BEDS ❑ Distance to nearest: Well rC7y Foundation A > Property Line � X. r a SEEPAGE PITSf ❑ Depth �SSize �.x��?�X/S� Number ' SUMPS 'Distance to nearest: Well X00qn Foundation Property Line EGD DISPOSAL PONDS ❑ a I hereby certify that I have prepared this application and that the work will tie.done.in.accordance.with San Joaquin county ordinances, state laws;and p 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 fib 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 rAll for all required inspections. Complete drawing on reverse side. 1 a Signed X Title: Date: FOR DEP RTMENT USE ONLY • `- 2-2 7 6 Application Accepted by Date Area F Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-36221 ❑ Manteca 823-7104 DC7 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 i INFO AMOUNT DUE AMOUNT REMITTER CASH RECEIVED BY DATE PERMIT"NO. •+EN 1324(REV.10/83) 3 EH 14-26 S. C_-.,C, &S r-Z"4 S -