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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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. Job Address 1,31ol `'S - u 99 City Lot Size a 3 M Mfg ti'Tu,0 Owner's Name �� / A�t1CIER�C ,�� Address �LP f � f,� IT d Phone Contractor J - ddress__L1 l�R_02e C __License No. 1 )_ )_ � Phone TYPE OF WELL/PUMP: NEW IVELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR i I OTHER Ll DISTANCE TO NEAREST: SEPTIC TANK 165' SEWER LINES DISPOSAL FLD.,A� PROP. LINE �� r FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS k)6 4JC INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 63/r 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1pomestic/Private ravel Pack ElTracy Type of Casing Specifications Ll Public ❑ Other ❑ Delta Depth of Grout Seal b Type of Grout OC/VI 1Z)k)tT Ll Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by _ I Repair Work Done ❑ Type of Pump H.P. Sta a Wojk Done Well Destruction ❑ Well Diame r rr,—�—J----- Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INS ALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is -� available within 200 feet.) Installation will serve: Residence Commercial __ Other ` Number of living units: Number of bedrooms �•J 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 r!Roundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth -----Size Number SUMPS ❑ Distance to nearest: Well 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. 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 applicantcall for all required inspections. Complet awing on reverse side. Signed X _ Y 'ss � _ Title: _ �/ � �/C . Date: !tom± FOR DEPARTMENT USE ONLY Application Accepted by Date �� Area Jr 1424 �3 Pit or Grout Inspection by �/ Y bate yl� Final Inspection by L Date7 X,o56 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 XManteca 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 IFEE NFO AMOUNT DUE AMOUNT REMITTED C 9 I RECEIVED BY DATE PERMIT NO. + EH 3-24(REV.1/95) (:\ l � �46�5 EH 14-26 O� . O \.�C_ ) _ -