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APPLICATION FOR PERMIT I-ow SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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.543 for sewage or No. 1862 for well/pump altd the Rules and Regulations of the San Joaquin Local Health District. j _O'�" / , 5U I (Gt{ A ! t 7 ' Job Address � 1 � - "r ►�� City_ __ � Lot Size ' 9:24-- t _ PM_ Ovrner's Name 76 N-V Address JACA:-�,(2~ A W V Phone l —3 Rt -36M Contractor's Name 1_4 License No. 05 6Z Phone TYP WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION El REPAIR 11 OTHER El DIS E 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 ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done �i Well Destruction ❑ Well Diameter Sealing Material (top 501 �3 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION;K REPAIR/ADDITION FJ 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 77 Character of soil to a depth of 3 feet: l� Water table depth T 1 SEPTIC TANK N< Type/Mfg A�('15 Capacity �1 r No. Compartments ■,. PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well _ Foundation Property Line LEACHING LINE 'Gel) No. & Length of Ines __L._ Total length%size ` ! ` FILTER BED ElDistance to nearest: Well Foundation lo Property Line SEEPAGE PITS Depth Size 2 i SUMPS ❑ Distance to nearest: Well Foundation_ �Q 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 workinan's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following:"I ce /that" the ormance of the work for which this permit is issued,I shall employ persons subject to workman's compensa tion laws of California." The applicant must I fo I requi ins ctions. Complete drawing on reverse side. � �] Signed Title: '" Date: / —1�(54— FOR DEPARTMENT USE ONLY / Applicati Accepted by c 1 _— DatArea Pit or Grout Inspection by Date 11 // Final Inspection by — Uate dditional Comments:[ } C� yt Q!�4�1 G (0 4 E ri b"1 ��Q 1� -14441 11A U nn �tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 104 ❑ Tracy 835-6385 G 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 RECEIVED BY DATC PERMW NIO. INFO I , ff CASH . EH 13.24(REV.10/93) _ �-f EH 1429 ttt