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= "'! APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ;t�� ,; 6 1601 E. HAZEL i ON AVE., STOCKTON, CA � Y, I�@� t. -� c � 1 ' Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APR N/1 S89 `` (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 complisnco with San Joaquin Linty Ordinance No.549 for sewage or No. 1662 for well/pump and the Rr�les`anr�Reg�atL h�o�f--c an Joaquin r � � �Ait Local Health Dido z/ r /0 /7 e 1 z - - , • -0 21 / r� P M_ ! f _ J(J _ ity Lot size Job Address — - Owner's Name _ Address �/j �I s� 4Z(A &_License No.. t .2 U/3 done 4� Contractor _�'d1� —Address_ TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT -1 DESTRUCTION L' PUMP INSTALLATION 11 SYSTEM REPAIR I^i OTHER Ll Oh SEWER LINES _— DISPOSAL FLD.W.� PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK __L7 _�1— PITS/SUMPS _ FOUNDATION-—_= AGRICULTURE WELL — — OTHER WELL_ •,. — i1 „`_r-moi 'i INTENDED USE- " —TYPE OF WELL-"PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ile Industrial G Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Type of Casio vlres -- Specifications Domestic/Private Gravel Pack 19 Tracy yp g— T of Grout — M Public Cl Other F1 Delta Depth of Grout Seal y� — I I Irrigation — Approx.Depth I I Eastern r I Surface Seal Installed by— p H.P. _ State Work Done F1of Pum _.. Repair Work Done Type p - — Well Destruction U Well Diameter Sealing Material Itop 50') .- Depth_ iI _ Filter Material (Below 501o se TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION l I DESTRUCTION I availlerwihin 20stem 0 feet-) if Public Sewer is s Installation will serve: Residence_�. Commercial _ Other Number of living units: Number of bedrooms — Water table depth S Character of soil to a depth of 3 feet No. Compartments SEPTIC TANK C Type/Mfg _ _ Capacity—. _-_ Method of Disposal PKG. TREATMENT PLT. 0 Distance to nearest: Well �. Foundation - . _ Property Line_ f LEACHING LINE U No. & Length of lines —. Total length/size _ - r Property Line .. , FILTER BED D Distance to nearest: Well Foundation P rtY 7 �• SEEPAGE PITS 1 Depth _ _Size Number A t Foundation _ Property Line — j SUMPS �❑ Distance'to nearest-. Well DISPOSAL PONDS [ ' � d_this application and that.the work will be:done.n_accordancewith.San-Joaquin_county.ordinances, state laws,-and .—- _ I,hareby_certify_rhat_I,have.prepare rules and regulations of the.San Joaquin Local Health Diltrict_ 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."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." I The applic$n ust call for all requir nspections. Com late drawing On r Side. ( r Title: _. _ Data; A� l Signed X r R D AR ENT USE ONLY / Q _ Date Area Application Accepted by Pit or Grout Inspection by _. Date.- Final Inspection by Date Additional Comments: ❑ Stk 466-6781 Cl Lodi 369-3621 ❑ Manteca 823-7104 n Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED H RECEIVED BY PATE PERMIT'N0. INFO . EH 13-24(REV.ii 4s �Ro r �� ©� It-1� `� `� 44 EN 14.28