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N..V APPLICATION FOR PERMIT * ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELLTON AVE., STOCKTON, CA Telephone (205) 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 Ryles and Regulations of the San Joaquin Local Health District. r Job Address 17,41.3c)�3 C c) /60"4'r City,45-4 A_) Lot Size_ 41464 04C PM Owner's Name Mew d Address Z?1/� 0411E Phone O Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW 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 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 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth El Eastern Surface Seal Installed by 1 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.), Installation will serve: Residence_2C Commercial— Other Number of Irving units: Number of bedrooms—_O i Character of soil to a depth of 3 feet: s,4Nd✓ G 1i0✓ /12In Water table depth SEPTIC TANK Fd' Type/MfgCe,ycQe1! Capacity_,Za o O No. Compartments PKG. TREATMENT PLT. ❑ Method of Disp_oral Distance to nearest: Well 1.2 4' Foundation VO ' Property Line LEACHING LINE LN' No. & Length of lines — Q,0 Total length/size f7 C) •� FILTER BED ❑', Distance to nearest: Well AX� Foundation a � Property Line/$S z SEEPAGE PITS ❑ Depth /OSize Number / s SUMPS ❑ Distance to nearest: Well _ Foundation /-93' Property Line Sr (A DISPOSAL PONDS ❑ .7 /O, 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 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." t The applicant must call for all requ'ed inspec'dns. C mplete drawing on reverse side. (,'. / '�� Signed X-4/ Title: O'f-tl�+�Gti Date: 6 J` FOR DEPA TMENT USE ONLY / I L Application Accepted by Date — / r Area oy Pit or Grout Inspection by Date Final Inspection by / ate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 XIVIanteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ' FEES MOUNT DUE AMOUNT REMITTED RECEIVED BY DATE INFO - PEAMIT'NO. EH ;324 1/98) ✓ e��y/ c, EA,429 �1S .S ( LS/ ps ��"S 197