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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (2091 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. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 1 yasc? NY. 1r ' "` Cite Lot Size A PM Owner's Name g ` Address * t �(> Phone7��i�../._`^— Contrac r AddressOp 8o -x)0 p License No��Z6r Pbone3kg TYPE OF WELL,'PU P: NEW WELL D WELL REPLACEMENT G DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C OTHER ❑ DISTANCE TO NEAREST-., SEPTIC TANK. ._,SEWER LINES DISPOSAL FLD. PROP ,LINE �,�,,,�� FOUNDATION ..__._..._. AGRICULTURE WELL OTHER WELL__ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation F - Dia. of Well Casing ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (•l Public -,IOther (-1 Delta Depth of Grout Seal - `Type of Grout 14rriyation _Approx. Depth ..� I Eastern Surface Seal Installed by. - Repair Work Done ❑ Type of Pump H. P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 1 Depth 'Filler Material (Below 5011 r TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/A'DDITION I i DESTRUCTION I 1 (No septic system permitted it public sewer is available within 200 feet.) ^/ I ? Installation will serve: Residence Commercial Other f r C Number of living units: Number o e rooms, ry Character'of soil to ade_plth of 3 feat: ' Water table depth v SEPTIC TANK Type/Mfg - Capacity -/-Q 0 No. Compartments PKG. TREATMENTPLT. 11y t ' y _,yL�1 F..- .•. - _Method of Disgosai .. _ Distance to nearest: ,,�� Well !4 Foundation !�Q_... __.__...Property Line__ LEACHING LINE ;,,❑ Nd. & Length of lines- Total length/size FILTER SED f!Y' 'Distance fo nearest: fWell # Foundation -- ProPeY rt _Line SEEPAGE PITS Depth Nur, : �.,,� ... -_ .. . SUMPS �:' Distance to nearest: Wail"� _' Foundation, ZLI PropertyfLine S � J DISPOSAL PONDS I hereby certify that I have prepared this application and that the -work will be done yccordance with San/Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di}trict. j. f f 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 st not employ any person in such manner as to become -subject to workman's compensation laws of Cali�?omia." Conuactol's hiring or sub contracting signatur 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." The applicant mus 11 fora uir nspections.:Complete drawing on reverse Signed Title: Date• FOR DEPARTMENT USE ONLY" y `.i �p Application Accepted by Date Area �_r , QV' ' . ,Y �` n Data it r Grout Inspection by Data t�� frnal inspection by �� - ! Additional Comments:J D Stk 466-6781 G Lodi - 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/ Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 +.EH 13-24 {REV, 1/85) t EH 1426 FEE INFOCASH AMOUNT DUE AMOUNT REMITTED CK k RECEIVED BY DATE PERMIT` NO. '�� f•� 9 -c�S 2a -b