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.i . fi Y, APPLICATION FOR'PERMIT s ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209)'466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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. Job Address _ Ci Lot Size !« PM I .��c�, Owner's Name `�{ Addressza 4 7 �� Phone� Contractor's Name License No 1+1+ „,,,_ Phone —'?,60-7 TYPE OF WELL/PUMP: NEW WELL ❑ ` WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 0 :r .SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES y' DISPOSAL FLD. PROP. LINE may. Y FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION'SPECIFICATIONS`` 3 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing u�r ❑ Domestic/Private -- ❑ Gravel Pack ry_❑ Tracy Type of Casing Specifications 0 Public ❑Other y ❑ ,Delta L Depth of Grout Seal Type of Grout ❑ Irrigation _-L''Appro g bepth; ❑ Eastern r Surface Seal Installed by Repair Work Done ❑, Type of Puriipp H.P. State Work Done_:� Well Destruction ❑ Well Diamet'i1 ' Sealing Material Stop 501.1 i Depth ' — Filler ftAate1 .rial (Below 50'1 TYPE OF SEPTIC WORK:-"NEW:INSTALLATION ❑ REPAIR/A OITION DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.l ! Installation will serve Residence Commercial '# Other�''" i Number,of living units �''• Number of bed ams ?� 1 ,. f� "'Character of soil to a depth_of 3 feet: `'� Water table depth 1.)11 i ) SEPTIC TANK Type/Mfo Capacity� C9C)_ No. Compartments Z . + PKG, TREATMENT PLT. q Method of Dis$osal rh Distance to nearest: Well 97 Foundation /6 Property Line 1_ r LEACHING LINE. ,No. & Len th of lines 7otai len th/size k 9 g FILTER BED ❑ Distance`to nearest: Well Foundation__;rz Property tine r SEEPAGE PITS Depth ize- - -Number — "' SUMPS 171 Distance to nearest: Well' 6P_ Foundation r� Property Line s A DISPOSAL PONDS ❑ s I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature..) 'certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant musts call for al�l.req, ired ins tions. Complete drawing on reverse side. Signed Title: �`'�1� Date: v e FOR DEPARTMENT USE ONLY .k Applicon Accepted by -Date Uy - —Ares Pit or Grout inspection by Date (Final Inspection b c ( I P Y DateQ Additional Comments: ❑ Stlk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Seryices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE , I INFO AMOUNT DUE AMOUNT REMITTED 'CASH A RECEIVED BY DATE PERMIT'NO, I ' + EH 13.24{REV.10!83) _ /`,1/$" g�'�O 07 EH 14-28 S .W � "� 7