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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICI 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 0Ou 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. i � Job Address } ^ /'`Y;� 4�`" ti City 9y%141 Lot Size ;y �y�'1� _ PM Owner's Name rt+f�l i_ J i, If�-r�� ¢� - L� � i, r" I' �f r r�t,T� AddressI r' ri- - Phone' ,�1 't Contractor CG/ / Address/f�r�z License No.o'r� 6 2-S Phone TYPE DF WELL/PUMP: NEW WELL Dq WELL REPLACEMENT ❑ DESTRUCTION ❑ C , PUMP INSTALLATIONIfI( SYSTEM REPAIR ❑ OTHER ❑ "V DISTANCE TO NEAREST: SEPTIC TANK ' J60 — SEWER LINES l Ud `F DISPOSAL FLO.h PROP. LINE _ ." FOUNDATION S'f AGRICULTURE WELL OTHER WELL PITS/SUMPS =-- ' 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t! ❑-Industrial ❑ Open Bottom d�-Manteca Dia. of Well Excavation Dia. of Well Casing ;'Domestic/Private kr Gravel Pack ❑ Tracy, Type of Casing P iy 6— ecifications 1"1 Public ❑ Cher - �} �l�S•S�/ � �.�,r) f-� Delta..-,-, Depth of.Grout Seal 1 yp/e of Grout ' - I I Irrigation ` ffApprox, Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump ', H.P. State Work Done- • f'r _ Well Destruction ❑ Well Diameter Sealing Material {top 50'1. Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION (.1 REPAIR/ADDITION I I DESTRUCTION.[ 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 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 Foundation Property Line LEACHING LINE Ll No. & Length of lines Total length/size { FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth Size Number SUMPS {_1 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 tules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:g g g: "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." I The applican st call or all required in pe tions. Complete drawing on reverse 'de. Es Signed X Title: +� �]�� _ Date: ' I , FOR DEPARTMENT USE ONLY _ Application Accepted by174�4Date S Area * Pit or Grout inspection by�" DateJFinal Inspection by Data Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 Cl Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE,i CK 9 i INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ' � 7 + EH 13-24(REV,1/85) L. EH 14.26 �L/' J h