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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA a AYE V ED Telephone (209) 466-6781 R F G PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 2 ,r98 (Complete in Triplicate) MAY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thework herei TPthioplCation is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Ru��{B.� OjC�n Joaquin Local Health District. pERhh� Job Address =t��kj: ` �_(-Q&V\Z City Lot Size----, PM Owner's Name `"`+'�S__ _�---- Address "t�y S•—[Z'�R'• 's�•Lo%Lk1 ho Phon,(3JL�)b^'-A —SLWt Contractor ' r ddress te&u rr, License No.4k&60 Phon TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X l� fli >, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE v FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS / ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ci Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications N-eC6,- iz „ -k F) Public Cl Other fl Delta Depth of Grout Seal 't'o c-0 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation_ Property Line LEACHING LINE ❑ No. S Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line �t SEEPAGE PITS I I Depth Size Number SUMPS t I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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. 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, 1 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 permit is issued.I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. r Signed X m00%,- • M a7�� Title: Date- for Ian C. Mac al pager of Environmenta aste managementServices FOR DEPARTMENT USE ONLY Application Accepted by na"rd CA,Is Date AI Area Pit or Grout Inspection by _. Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 O Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9'5201 FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT'NO. INFO ♦ EH1324 IREV.1/a 5) . �]) EH 14.2e !II 1S