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y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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. Job Address 13023 Fabi ait 6Ya.v _ City'T�rpC r _ Lot Size PM Owner's Name jay � __ly n0�r Address Phone J C Contractor's Name Degg L11sell License No. Phone ft It _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION C�7 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TAN SO SEWER LINES DISPOSAL 171,0'.•5n PROP. LINE _1 Q FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q ❑ Industrial ❑ Open Bottom ❑ MantecaDia. of Well Excavation J'�st Dia. of Well Casing mt LX Domestic/Private IX Gravel Pack Ex Tracy Type of Casing p:VC ItQ' Specifications . ❑ Public ❑ Other ❑ Delta Depth of Grout Seal _ Type of Grout ❑ Irrigation —.Approx. Depth ❑ Eastern Surface Seal Installed by . urn Cold.rn Ct 0 C Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction d► Well Diameter � Sealing Material (top 50`) b e iit ord t e Depth 80 Filler Material iBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial, Other Number of living units: Number of bedrooms -- , Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK C] Type/Mfg Capacity No. Compartments PKG.-TREATMENT PLT. ❑ Method of Disposal Distance to�nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ElDistance to'nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 all for all coduired irispections. Complete drawing on reverse side. I Signed Title: Cop-tractor Date: 10=31-85 i FOR DEPARTMENT USE ONLY Application Accepted by Date Area i - T Pit or Grout tnspection_by x T Date/ Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE i INFO AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT"NO. I f 5- + EH 1314-26 G�-0 1313 P EH 24(REV.10!83) ; p i _ �� (� 3--�`s