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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYANENT 1601 E. HAZELTON AVE., STOCKTON, CA ReCEIVED Telephone 42091 466-6781 , O 199 0 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED SAN JOA pUk3LIC QUifV csr�UNTY I (Complete in Triplicate) E U1Rp HEALTH�E-FpViCCS i. NM scri e Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein describe made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ii-e7 City... Svoct o_ LotSize PM Ilk a Owner's Name �i�• �Pva�h Address W314 S• Phone b� " 17 1 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ A`Uti✓-GI.-' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �jp14 go/rwc�C DISTANCE TONEAREST: SEPTIC TANKA SEWER LINES !-a &t— DISPOSAL FLO._Lh', '2c PROP. LINE , ' I FOUNDATION 5' AGRICULTURE WELL NA OTHER WELL__HPITS/SUMPS INTENDED'�USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial !I1 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation -7.2-V I- - Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications (1 Public ❑ Other f1 Delta Depth of Grout Seal _1-066*a-'11,+�ype of Grout I i Irrigation _..Approx. Depth I I Eastern Surface Seal installed by 0MIIE- am& 0"0 irt�VJCA-y -_4t P/c rc alb - Repair Work pone ❑ Type of Pump H.P. State Work pone Well Destruction ❑ Weil Diameter Sealing Material (top 50'1 I1I Depth Filler Material (Below 501 A TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION ( I iNo septic system permitted if public sewer is lJ� available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character ot�soil to a depth of 3 feet: Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ' Ct Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BEDElDistance to nearest: Well Foundation Property Line i, SEEPAGE PITS it Depth Size Number n� SUMPS II! Cl Distance to nearest: Well Foundation Property Line T DISPOSAL PONDS ❑ 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 orf 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 fol 1pwing: "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 call f�.Zns II rquired i . Complete drawing on reverse side. O� Signed I I Title: Date:It FOR DEPARTMENT USE ONKY r} q Application Accepted byFF AA Date ` 1 I Area Pit or Grout In l�pection by0 A142-1'C. , Date Z 17- & h Final Inspection by_- • Date 7- d d� IIII Additional Comments: El Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Retbrn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I it I ,FEE AMOUNT DUE AMOUNT REMITTED CK INFO RECEIVED BY DATE PERMIT'NO. ♦.EH13-26(REV.Iik51 -:?) .S, {� 3�j (� a 1 4J V EH 14-28 Ll - O C�