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s APPLICATION FOR.PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 .; PERMIT EXPIRES 1-YEAR.FI16M'DATE ISSUED.1j .rO,a . t .�y,,:,.c. -• (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereimdescribed. This�app)'ieation is made in compfience with San Joaquin County. Ordinance No. 544 for sewage or No: 1862 for waif/pump and -the Rules and Regulations of the San Joaquin Local Health District. j 11,;.r �� ~,� WRQ Tfl ,.tti^. iPl.�i ��. a f, rr.•..-�, r r �p�/ All �'rr, ��•� .^! i ISI t`� St r ; ;'>*"I Y1 .r. . r.. �� , f . 'rti! Job Address ly� 1V .t�t, Ci ^ Lot ,Size t GI CJ PM If Owners Name ;f 1 X �atAddress - n �'' 3 84- Contractor's NaLicense No. ma( /l D ��'d Phoma TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT ❑ 1 DESTRUCTION ❑ r—pUMP`INSTALTATION-L]--SYSTF-M-REPAIR-7------- ""OTHE'-EG DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _.DISPOSAL FLD. - PROP. LINE FOUNDATION, AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE ❑ Industrial ❑ Domestic/ Private 0 Public ❑ Irrigation Repair Work Done ❑ Well Destruction ❑ TYPE TYPE OF WELL PROBLEM AREA CONSTRUCTION SNtt:lh- ,A i 1UNZ) ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Gravel Pack ❑ Tracy Type of Casing '`xs ❑ Other Detta is Depth of Grout Seal Depth4 ❑'Easte C :Surface Seal installed by__ ---Approx. Type of Pump H. P. State Work Done _ Well Diameter / Sealing Material (top 501 �`• Filler Material (Below 50') Dia. of Well Casing Specifications Type of Grout ; Depth NEW INSTALLATIOWY REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Z available within 200 feet.) Installation will serve: ResidenceEom_mercial Other ~" L A V Number of living units: F, Number.of,hedrooms t -Y w Water table depth Character of soil to a,depth,of 3 feet:. � C �" DO No. Com ariments . SEPTIC TANK � Type/Mfg -., i ' � - r Capacity �� p S _ '� • �. PKG. TREATMENT PLT. C:P I , ?'= ` I Method of Disposal �. '4-J - 'Distance to nearest:11100. i Fo ntJation -� Property Lina f 5 \ ' - .►� LEACHING UNE—) o, & Length of lines �� Ta&length/size��U r r FILTER BED , ❑ Distances nares Well -_{Ong Foundation Property Line Number SEEPAGE PITS9 }D�epth r s I i. SUMPS ❑ f Distance to nearest: —Well 1 d {"-foundation 4 Property Line S _ DISPOSAL PONDS ❑/. li w I hereby certify that I have prepared.this'application and that ttie work will be done in,accordance•with �Sari Joaquin county ordinances;\state laws, and rules and regulations of the San Joaquin Local Health District. • ` ,. Home owner or licensed agents signature certifies the following: "I ceRifY/that in the performance of-tfie`�+ork•for which this permit is wed, I shall not employ any person in such manner as to become subject to workman's oompensatlon laws of Californ`Ia. ;C idtiactoes hiring o. sub -contracting signature certifies the following: "I certify that in tKe performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." f � i The applicant must call for I required iHspect*ns.£CC-omplete.drawing-anreverse side.' (�'��7J (} Date: s1 Z Signed X— aMTl�c-�C Title: v ` _ y _1. R v > ~< FOR DEPARTMENT USE ONLY Date Area Application Accepted by ; �'�� Pit or Grout Inspection by Date Final Inspection by a c:+ Additional Commentsi: ❑ Stk 466-6781~`+' ":: n Lodi 369-3621 ❑ Manteca 823-7104 'C7 Tracy "836&385 f Applicant - Return .all copies to: Environmental Health Permit/ Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I + EH 1324 (REV. 10/83 EH 14-26 FEE' AMOUNT DUE' AMOUNT REMITTED �JC�AKSH '~REC�IV�D BYRIDIATE PERMIT:MO. INFO`t' © C.,