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APPLICATION FOR PERMIT SAN ,►�QUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ./ Telephone 12091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) c ton a Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This app n made a compliance with San Joaquin County Ordina cej�`�for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. i (j 4(`6 N _//IJ/ City ff O ( Lot Size�� PM e. ` h taa � pp Job�Address � �;� _ �J :��, I / _ phone Address I Owner_ �. RIr-•--•^'-�' +—__ �,>r Phone IF, 6 License No. Address DESTRUCTION ❑ N1Q/1/'170 R/N/ Contractor NOS WELL REPLACEMENT ❑ TYPE NE WELL OTHER ❑OF WELL/PUMP: SYSTEM REPAIR ❑ PROP, LINE — ------�— PUMP INSTALLATION ElSYSTEM FLD. SEWER LINES OTHER ELL PITS/SUMPS _- DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL FOUNDATION TYPE OF PROBLEM AREA CONSTRUCTION SPECIFICA IONS Dia. of Well Casing �.t_� -- INTEN�ED USE ❑ Manteca Dia. of Well Excavation G Sp,cifications fbt t t0 ❑ Open Bottom ❑ Industrial Gravel ❑ Tracy Type of Casing DomestIAR Gravel Pack jp Type of Grout V ❑ Delta Depth of Grout Seal Public ❑ Other Surface Seal Installed by ❑ Irrigation __Approx• Depth ❑ Eastern tate Work Done T of Pump H.P. _ c� K1 E� 1 Repair Work Done ❑ Type Sealing Material (top 50'1 { �eit,�_Q(��d y�/ell Destru ti n Well Diameter ' d Filler Material (Below 50'1 /ti011Et0 W Depth 3_._®� 'i available wlthln 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION O (No septic system permitted If public sewer Is Installation will sen'e: Residence—_ Commercial_ Other Number Number of bedrooms Water table depth --- 6 Characterr living units:of soil to a depth of 3 feet: Ity No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal K PKG. TREATMENT PLT.❑ Property Line r Distance to nearest: Foundation Total length/size LEACHING LINE ❑ No. & of lines _ Property Line FILTER BED ❑ tante to nearest: Well Foundation Number SEEPAGE PI ❑ Depth --Slza Foundation Property Line (y l' SUM ❑ Distance to nearest: Well S ❑ state laws, and OSAL PONDS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin cch this p manias. I shall not rules and regulations of the San Joaquin Local Health District. I certify g compensation laws of California.'Contractor's hiring or u workman'scompensa- signature Home owner arson inor suchmanner.as toed agent's rbeco certifies subject following: wlorkman's r in the performance of the work for which this permit is issue employ any p permit is issued,I shall employ persons certifies the following:"I certify that in the performance of the work for which this pe tion laws of California:' The applicant st call for all squired i s tions. Complete drawing on reverse side. Date: Title: Signed p FOR DEPARTMENT USE ONLY / O /f[ Date ` � � Area ! �� Application Accepted by I Date ll� Date From I°spection by Pit or Grout Inspection by Additional Comments: ❑ Manteca 823-7104 ❑ Tracy 83ve 5 _ f ❑ Stk 4e6-6781 O Lodi 369-3621 $tKt gppli nt- Return all c pies tp• Environ mental aAvBox `• ' '6+ p'i""� DATEPERMIT'NO. RECEIVED BV IF FEE AMOUNT DUE \INFO � 1\ /. & SZ'7-1{p EH 112/(REV.rr 951 `T EH 1429