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vast APPLICATION FOR PERMIT �R SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ��t79 41 Telephone (209) 456-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED• AUG 2 0 I9?7 (Complete in Triplicate) ENVIROMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work he�e��L1d�p�Ifi�EQcation is made in compliance with San Joaquin County Ordinance No.569 for sewage or No. 1862 for well/pump and the Rules and R9�'ulatl6ns of the San Joaquin Local Health District. Job Address hlr Z, 741/=nz fli ppCitty L—itr f- Lot Size PM Owner's Name �(s,�(� Address ,�aI1 t+-[erc , lzzi� Phone A j^of7 Contractor Q J' Address l.36�.C lAli-rle� C, <e-'acc� License No.� x-373 Phone - J 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 M ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 O'bomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other n Delta Depth of Grout Seal Type of Grout_. I Irrigation Approx, Dep4i I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. �� -State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') - Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is i available within 200 feet.) Installation will serve: Residence_ Commercial= Other Number of living units:_ Number of bedrooms Character of call to a depth of 3 feet I 1. Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT.❑ 1 _ 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 I y SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 'r 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, 1 shall not employ any person in such manriet as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:41 certify that in the performartce of the work for which this permit is is_wed,1 shall,emdoy persons_whject to workman's campensa- - tidri laws of"Catitorni$: "` �' _ The applicant Aggq(��t`ca/l/l for all requir insspeecticatet Completer drawing on reverse side. X�j'7 Signed X •�'' `"'tom "`� �`-title: /_�.P / Date: V /V-iP7 /� '� Application Accepted by •r t - FOR DEPARTMENT USE ONLY Date Area 101 / 7` Pit or Grout Inspection by Date Final Inspection by Date Addilional Comments: ❑ Stk 456-6781 ❑ Lodi 3693621 ❑ Manteca 823-7104 ❑ Tracy 83543% 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. IN �7 CASH x EN 11a1'REV .,rxSt JG� � EN 1.]e