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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA r Telephone (209) 466-6781 uSe � PERMIT EXPIRES 1 YEAR FROM DATE ISSUED L.t w°• (Complete in Triplicate) r 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. `J /y r r AV /0 fic Its PM L Job Address ` `�/ � �+ � �� t � Ci/ty'F�r-Ntpt Size Owner's Name f �}L Address �A'Y�G Phone _ _ _ OAkili4�t L 2 ._ y/1 7 Contractor l-/�-SO YI�C1 1ttV Address .2 1117 41Q License No.�J� a Phone LTYPE OF WELL/PUMP: NEW WELL E3 WELL REPLACEMENT 13 DESTRUCTION 11 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FUD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS LINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public_ ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed.by 1 Repair Work Done ❑ Type of Pump H.P. State Work Done Li Well Destruction ❑ Well Diameter Sealing Material (top 509 i Depth Filler Material (Below 509 TYPE OF SEPTIC WORK: NEW INSTALLATION A REPAIR/ADDITION ❑ DESTRUCTION Cl (No septic system permitted if public sewer is available within 200 feet.) L Installation will serve: Residence-4 Commercial_? Other Number of living units: ___ Number of begrooms L Character of soil to a depth of 3 feet: /^ - ©ft&* Water table depth SEPTIC TANK . Type/Mfg PAA.-Cli57" L°O))CI (Capacity,_ L !6(5C7 No. Compartments < L I PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: WeIlIO-f'bFoundation A_ <-f- Property Line LEACHING LINE •�, 1� No-& Length of lines - -' ""'` �" ' "MdTal length/size d ! FILTER BED ❑ Distance to nearest: Well t�'fFoundation -4Z77' Property Line SEEPAGE PITS ❑ Depth Size i4umber SUMPS Distance to nearest: ,fg J FoundaligD.. ® 'f PropertyLine rap DISPOSAL PONDS El /7� 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 L rules and regulations of the San Joaquin Local Health District. Home owner or lidensed 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 laves Of Califorlaja."Contractor's hiring or sub-contracting signature certifies the following:-"t 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 ofCa" a.". The applicant mat t c for all re fired inspec' ns. Complete drawing on reverse side. ' Signed Title: _ Date: /w / FOR DEP RTMENT USE ONLY D Application Accepted by V v Data �` - Area /- LPit or Grout Inspection by II Date ,�I. Final Inspection by Data P�i� Additional Comments: C1fiFh Ayr U"4, py'r11,K) µ-c cel h-<v.b <LJJ I�'17 Y+/ C 1e.i/+C v+ r'1 fWtGh .S /fs y� L ❑ Stk 466-6781 ❑ Lodi 369-3621 11 Manteca 823-7104 ❑ Tracy 835-6385 _J'v'ro ^n 5-4 7 c 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 DAT - CASH LEH/3INFO 24(REV.1/85) /3 OS { EH 10.26