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APPLICATION FOR PERMIT X11 JOAQUIN LOCAL HEALTH DISTR1r *1'601 E. HAZELTON AVE., STOCKTON, C Telephone (209) 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 weal/pump and the Rules and Regulations of the San Joaquin Local Health District. , - I Job Address 7 w City r�� Lot Size PM Owner's Name zi f'-10" � / CI 4 d Address /� E Phone ,31-3,093 Contractor S i.t.+r. Address Z9L5 E. dL1y r 4jf License No. 51 Z LCr S Phone 4/(.T,- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT G DESTRUCTION Prdss&%re Grow" PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Z rt • Industrial ❑ Open Bottom u Manteca Dia. of Well Excavation R" Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing PUL Specifications Vi Public n Other n Delta Depth of Grout Seal Type of Grout )fC 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 �9-r Well Diameter ;6.Well Material (top 501 Depth 100' Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted it 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. Compartment PKG. TREATMENT PLT. ❑ Method of Dispos AYMENT Distance to nearest: Well Foundation Property Line R CEIVED jAN 16199 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Weil Foundation Property LineSAN JOAQUIN COUNTY — JUbLl(;HEALTH SERVICES SEEPAGE PITS I I Depth Size Number SUMPS Q Distance to nearest: Well Foundation Property tine 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 Dittrict. Horne owner or licensed agent's signature certifies the following: "1 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." Contractors 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 applica ust call for all reqpired inspections. Complete drawing on reverse side. Signed X Title: — !r►�/1cIs4-4V-- _ Date: L- £x� FOR DEPARTMENT USE ONLY Application Accepted by Date Area 3(� `-' Pit or Grout Inspection by w t_ Date 12-Final Inspection by _ Date a �1 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 a Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 lUy/l"J FEE AMOUNT DUE AMOUNT REMITTED CASRECEIVED BY DATE PERMIT NO. H INFO r SCA . EH13.24fRTT/�O:Jc�Ev.I/M51 ►^ /uQ I.-?--)VJ� 3 EH 14.n `k+