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I .. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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. � 1 - Job Address p� (� f v ^'` �" � City�!`'r" Lot Sire PM Owner's Name 1AY �S � w dd s 1'-ZU N - t UfJS� {� �l�Phone �- co` (A-13 Contracior Address !" License No. Phone— -TYPE OF WELL/PUMP: . .. a .NEW WELL ❑ r WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - D FLO. PROP. LINE FOUNDATION AGRICULTURE WEL OTHER WELL PITSISUMPS ] INTENDED USE TYPE OF WELL PROBLEM AR ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ ca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel:Pack- Tracy Type of Casing Specifications l-1 Public Cl Othe ❑ Delta T Depth of Grout Seal Type of Grout _ I I Irrigation —_Approx. Depth'• I ] Eastern Surface Seal Installed by - Repair Work Do Type of Pump H.P. State Work Done , k Well D ction ❑ Well Diameter " Sealing Material (top 50') Depth "Filler-Material (Below 501 A 1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l I DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.4 Installation will serve: Residence` Cornmerci5l_'' Other. Number of living units: Number-of-bedrooms Character of soil to a depth of 3 feel: Water table depth SEPTIC-TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal aDi s ancerto_nea est:n Well F undatio Property Line 71c LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line f SEEPAGE PITS l I 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. I 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." ,!r . T t t call for all re it i do . Co late drawing on reverse side. r a S Signed Ile: Date: t FOR DEPARTMENT USE ONLY. Application Accepted by \Vlzl�CSL Date y' f' Area �j Pit or Grout Inspection pate Final inspection by Date9/2—/97 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Q Mantec 823-7104 ❑ Tracy 835-6Md Applicant turn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk. CA 9 1 pP - R� 7 � 4YO��Yf'r� �" l FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO r EH 13.24(14 EV.I/n 51S EH 14-26 F� f