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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON•�AVE., STOCKTON, CA.. Telephone (209) 466-67$1 k PERMIT EXPIRES 1 YEAR FROM DATE 71§SUED _ r (Complete in Triplicate) 1 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.548 for sewage or No. 1662"for well/pump aqd the•Ryles and Regulations of the San Joaquin .Local Health District. - :;. i •- - • lSfJi�d� 'T 10 ne ' Job Address �L31� ra 3 �;��v�. 6A,,;To6 City 7R14 C Lot Size / PM "; �1''� �i•'fig.:- ri i '; /' Owner's Name P. �15��Ab' Address W7� �sz~ Phone ContractorAl i �_ Address 2.0/ ley 7464License No.Q Phone �FS� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER, F DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. "' J PROP. LINE a FOUNDATION AGRICULTURE WELL OTHER WELL' PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS I VJ ❑ Industrial D Open Bottom ' ❑ Manteca Dia. of Well Excavation Die. of Well Casing ❑ Domestic/Private } u Gravel Pack D Tracy Type of Casing Specifications I ! 9D D Publicr ❑Other ❑ Delta Depth of Grout Seal T C ep ype.of Grout i ❑ Irrigation —Approx. Depth D Eastern Surface Seal Installed by ' Repair Work Done ❑' Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 601 1 Depth Filler 1vaterial�(Below.50'1 1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION C ;DESTRUCTION ❑ (No septic system permitted if public sewer is , available within 200 feet.) F Installation will serve: Residence Commercial Other Q Number of living units: Number of bedrooms : Character of soil to a'depth of 3 feet ' Cil C t i r s, - Watel table depth SEPTIC TANK ? ElType/Mfg�}�.t�1y Capacity vo No. Compartments �� 0� PKG. TREATMENT PLT. ❑ +�Ai r, Method`of Disposal 3 s Distance to nearest: Well - Foundation Property Line f•..r LEACHING LINE No. & Lehgth of lines �/, l� '� Total length/size l O 1 (1 FILTER BED Distance�to nearest: Well n Foundation- Property_Line 4 ! SEEPAGE PITS ) C Depth I Size ' X Number t;� SUMPS Distance Ito nearest: Well Foundation' Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application-and-that-the-work-wilI-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 became subject to workman's conipeetation-laws of California."Contractor's hiring or sub-contractin&signature certifies the following: "I certify that in the perfonnar'Ice of the work for whichthis permit is-issued,I shall employ persons subject to workman's compensa- tion laws of California.", The applicant must call-for II red inspections. Complete draWing on revorse side. l } �.�v i Signed Ttls %ciP % Date: OR DEPARTMENT USE ONLY .Application Accepted by •I f�i� /f/ Date �� X 7 �' Area Pit or Grout Inspection by E Date ! Final Inspection by Date �7 Additional Comments: - i i Stk 466-8781 iD Lodi 369-3621 ❑ Manteca 8217104 C Tracy 835-6385 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE ( AMOUNT DUE I AMOUNT REMITTED CK# RECEIVED BY _,DATE-�T P- tN11J_NO. —CASH.-- i a EN 13-24iREV.l!P S: 4 �S-0 v ._. �>:.�, �.= :' ; c t Z 3 0 � t57ISS/ L. 1 � EH 14-28 - . - r t•^7 X111:'-,' -. v mow...- �+.a+JR w.--+rY•:,•�i•aytyq�•. r .o ..•.. -. _-_.— -.--