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APPLICATION FOR PERMIT 6 SAN JOAQUIN LOCAL HEALTH DISTRICT ,. s 1601 E. HAZELON ON AVE., STOCKTON, CA p AY M ,p l Telephone (209) 466-6781 REGEJV E PERMIT EXPIRES TYEAR FROM DATE ISSUED i. 2198 (Complete in Triplicate)' MAY y� tti� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work here' 'FpA•1.'�)A lleition is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the RU I > i1S n Joaquin Local Health District. YEI ' Job Address �OV` •- ^�Y�-•�= City Lot Size, PM Owner's Name S �lt>L + Address S• ' ,`d Phan 1150 Contractor + �� l ddress 1, uc'(X_ °13E]�� License No. PhanX&Iq i' TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 460 �3-��11'?�� 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 I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing h r ❑ Domestic/Private ❑ Gravel.Pack ❑ Tracy Type of Casing" Specifications Nkc&" IZ i`l Public n Other ) Delta Depth of Grout Seal '-k'a Q0 Type of Grout a _ I I Irrigation —.Approx. Depth I 1 Eastern Surface Seal Installed by ' Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') u Depth • Filler Material (Below 50'1 0 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION l I Wo septic system permitted if public sewer is # available within 200 feet./ Installation will serve: Residence f Commercial Other _ Number of living units: Number of bedrooms z ii Character of soil to a depth of 3 feet:;~ Water table depth SEPTIC TANK ❑ TypelMfgs Capacity No. Compartments TM PKG. TREATMENT PLT. ❑ a Method of Disposal Distance to nearest: Well Foundation Property Line Ji E LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS I I I Depth t Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 17t I hereby certify that I have prepared this'apptication,and that the work will be done in accordance with San Joaquin county ordinances, statei!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,jll 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,l shall employ persons subject to workman's compensa- tion laws of California." I The applicant must call for all required inspections. Complete drawing on reverse side. Signed X • Title: Date:, for Ian C. Mac ar an , pager of Envi.ronmenta aste Managementervices FOR DEPARTMENT USE ONLY Application Accepted uy " yl� C� Date Area Pit or Grout Inspection by t Date Final Inspection by OT Date Additional Comments: 3 h rs I O Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 635-6385 y ' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.; P.O. Box 2009, Silk., CA 95201FEE ]M INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO" + EH 13-24(REV.1/8 5) Ulf • .EH 14-28 J �- �� 3 ``^ 1p p IF