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j APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 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. Job Address &qo J r^J/ll�ll� City Lot Size+3 C PM Owner's Name I�A ale_/-7,96 Address _ P6: a-3 Phone 47 Contractor's Name License No. /5.]�$oZ Phone ll TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ; PUMP INSTALLATION P _ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES` DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑.;Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta 'Depth-of Grdut Seal- Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by _� I Repair Work Done ❑ Type of Pump H.P.' State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 �} TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑, DESTRUCTION ❑ (No septic system permitted if public sewer is ti t available-within 200 feet.) W Installation will serve: Residence_ Commercial_ Other 1_e .� " Number of living units: --I— Number of bedrooms Character of soil to a depth of 3 feet: i Water table depth SEPTIC TANK Type/Mfg E.44, Capacity av 6A1--No. Compartments 1 1 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well e!0! Foundation Property Line LEACHING LINE Y.-.,No & Length of lines Total length/size it FILTER BED ❑ Distance to nearest: Well Foundation ..Property Line a SEEPAGE PITS ❑, Depth Size Number SUMPS ❑ Qistance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have_preparedthis application and that the work will be.done-in accordance with'San'.ioaquin 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: "1 certify that in the performance of the work for which this permit is issued,I shall-employ-persons subject to workman's compense- tion laws of California." <. ` The applicant must call`for atlJ qui* inspect' ns. Complete'drawing on reverse side. },k ,ti+ • tr Signed Xr� �,.:_ '_ Title: "' Date: FOR DEPARTMENT USE ONLY Application Accepted by _ r u...� Date`:' - 3 r�g Are Pit or Grout Inspection,by. -- Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 � F - INFO _._.�_. _:_._._ � - C ----- ,__�.,..,.-. .._.—_...--.....r.�---•-"-- -- FEE AMOUNT DUE AMOUNT REMITTED CK# 7 y" RECEIVED 8Y DATE PERMIT"NO. - .. ASH.. .__._......._, ---DATE- - . + EH 13-24(REV.10/83) �� o EH 1428 S�1/otr ki, _k.-7F