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r i i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 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 l Local Health District. Job Address T:de Rd' City CVAI Lot Size Ao 09"'o-" PM Owner's Name ,0ly _- _— Address`v6o 3�,V-. �e• �----._..._... .. .----- Phone Contractor d� Address 4M J9C9CJ1J,T 471*1 !!!P X � phone License No. TYPE OF WELL/PUMP: IfNEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS s . INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Puk lic F1 Other 1-1 Delta Depth of Grout Seal Type of{Grout _ I I Irrigation —_Approx.+Depth l I Eastern Surface Seal Installed by _ Repair Work Done 0 Type of Pump H,P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material stop 501 �r+ ----- - - Depth LFiller Material (Below 501 `'a •.E __ TYPE OF SEPTIC WORK: NEW INSTALLATION IK REPAIR/ADDITION I I DESTRUCTION d„1-(No-septic system permitted if public sewer is { f available within 200 feet.) If 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 r /1 SEPTIC TANK ;R Type/Mfg4 f, i !Capacity /20t' I No. Compartmilts_ I V J PKG. TREATMENT PLT. 0 t 1� Method of Disposal # Distance to nearest:: Wel! r�� ou ndation �� Property Line LEACHING LINE { No. & Length of tines' �'� 00 z Total length/size g FILTER BED ❑ Distance to nearest: Well' r �, Foundation 4W f Property Line r t SEEPAGE PITS I I Depth Size Number l SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS_—...❑,y�- . 1 hereby certify that I have prepared tfiis 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 musl call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: '��'�q/ { FOREPART NT USE ONLY Application Accepted by Date Area ®�� Pit or Grout Inspection by bate Final Inspection b 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO._ ...... INFO CASH ; + EH 13-24(REV.1 95) EK 14-29 WA -# 31v a t