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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209).466-6781 t;AY A 4 044 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) � �� " �� HEALTH DISTRICT I 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 Joaquiri:County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District:n' Job Address 394 C. ! -41lu &_1 City Lot Size PM Owner's Name � srLQGt�t) Address 394/1 co, / r�vcl�/I )_Aalr_&AaAone 92 4868 Contractor's Name License Na. 49+0- Z/15 Phone �a TYPE OF WELL/PUMP: EW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION/✓�%,� SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK, `QQ "� SEWER LINES - _ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �f ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing �l yDomestic/Private Y Gravel Pack ❑ Tracy Type of Casing 10 ye, Specifications ❑ Public ❑ Other I ❑ Delta Depth of Grout Seal �/��" Ty of Grout ❑ Irrigation --Approx. Depth LIEastern Surface Seal Installed by 'r Repair Work Done ❑ Type of Pump H.P. State Work Done f Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth I Filler Material (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is S, available within 200 feet.) Installation will serve: Residence I Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation ' Property Line f r SEEPAGE PITS ❑ Depth .Size Number -;.SUMPS. .❑ Distance to-nearest: = Well -;r Foundation= — Property-Line — - -- 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. 11 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 applica et'Mi'st call for 41 require i pections. Complete drawing on neve side. Signed ' Title: Date: FUR DEPAR ENT'USE ONLY 6U Application Accepted by Date / " Area Pit or Grout Inspection b �+� Date �� Final Inspection by Date r Additional Comments: r u4-et .f 'i5 ❑ Stk 466-6781 ❑ Lodi 3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 O �� /7+ r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 r,Co ake— I ` T k FEE AMOUNT DUEJ AMOUNT REMITTED CK* RECEIVED By DATE PERMIT'NO. INFO CASH + EH1324(REV.10/83) I� EH 1426 L\ S