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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 (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. i� C 1 Job Address , } City /�IAC.4 Lot Size ►4� PM 4t Owner's Name G�.�4P_�nfZA Address i> �� Phone Contractor's Name z �L/�a( L� License No. S-/ y Phone t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE ENT O DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM FfEPAIR C OTHER ❑ 4 DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLIX PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C industrial C Open Bottom O Manteca Dia. of Well Excavation : Dia. of Well Casing G Domestic/Private C Gravel Pack O Tracy Type of Casing Specifications t ❑ Public O Other C Delta Depth of Grout Seal Type of Grout D irrigation —Approx. Depth C Eastern Surface Seal Installed by �1 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material atop 50'1 C3 Depth Filler Material (Below 60'1 TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/ADDITION DESTRUCTION C (No septic system permitted if public sewer is t available within 200 feet.) �a y Installation will serve: Residence_Aff Commercial_ Other ,� + Number of living units:_J — Number of bedrooms_,I - u� i 1) -- a Character of soil to a depth of 3 feet: I ,l o.dl�l Water table depth �� C SEPTIC TANK ❑ Type/Mfg i Capacity No. Compartments PKG. TREATMENT PLT. ❑ �� Method of Disposal X Distance to nearest: Well r~r � Foundation Property Line � r - LEACHING LINE ❑ No. & Length of lines 1,2 V -Z� t Total length/size FILTER BEDX Distance to nearest: well1 4911- <rFoundation T Property Line�O SEEPAGE PITS O Depth } Size -... I Number I SUMPS Q Distance to nearest: Well Foundation ,Property Line r DISPOSAL PONDS ❑ • i, ...� '= 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. ,1 Home owner or licensed agent's signature certifies.( fie foliowiAg:_'I certify that in the performanceof 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 perrtvt,is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must tail f all iced inspections. CVmplete drawing.on reverse side. - ; Signed --Title- .�+_:_�tt�[� r+ Date: / /FOR DEPARTMENT USE ONLY 1' ; `M i r Appllcation Accepted ,1 �' ~- -.p~e ��I 'v I Area by - i i �� ._r^-- *,.� � ,..� � ) /� yt�. ,., .. .,6 Pit or Grout Inspection by /eft T Date t' Fi_na_l Inspection by Additional Comments: 0 Stk 4666761 O Lodi 369-3621 , anteca.-823-7104 -C1.Traoy,.W56M Appficant-Return all-coples to:Environmentat ea 'Pe'imif/Sanrioes 161=E:=-Hazelton Avi:'P:O. 86x-AW, Stk.; CA- 5101, FEE AMOUNT DUE -AMOuNT_REMITTED r Y` ` .. INFO CA"SH"` ��flECEtVEO 87 r `_'DATC- PERMIT_'N0. 1 EH13,21(REV.10/89! S O o �.EH 14-26 Li