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�. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT , 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 4�11 3) PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SEP 2 u 1994 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the ��j n `flbedplication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the f u'Ie 3�PJ�fT{�2lbfts Nt tln Joaquin Local Health District. S' l l/ ttt��'��CVVV�1'l. Job Address ` City 0-6C"ty� Lot Size PM Owner's Name � hdJ re Address / S fire er �Phon� S—Z7 Contractor WO%G w t� Df'1` Address �'4aT( ��b . ''`� �a CA License No. 5 0�b 3 Phonne) 3�Y_y30d TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER--g( DISTANCE TO NEAREST: SEPTIC TANK Zoo SEWER LINES DISPOSAL FLD. VA PROP. LINE FOUNDATION AGRICULTURE WELL SQo OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIOfy V /, L7 Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation_ DiaWell Casing 11 Domestic/Private IXGravel Pack $<Tracy Type of Casing Specifications FI Public F1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I 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 Depth Filler Material (Below 501 —_ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 Di§trict. 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 become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I cert.,y 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 mist call for 11 required inspections. Complete drawing on raver a side. Signed X J1)1~I Title: o +�,f Date: FOR DEPARTMENT USE ONLY 9 Application Accepted by „ ` ` Date ` Area Pit or Grout Inspection by Date 3D Final Inspection by_ Date 77 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 3-576 / Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO L�FEE AMODUNT DUE AMOUNT REMITTED CA K / RECEIVED BY Q DATE PERMIIT'NO. 4 EH 13-24(REV.ii R a) EH 14-26 ((JJ 111 T' /