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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA I 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. +, :i ' ) Job AddressCity' O % Lot Size D — 7 7 PM Owner's Name � Address �313 IS: hone S 1 Contractor � �y N r Address License No. Phone T WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEARES TIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDA AGRICULTURE WELL OTHER WELL S/SUMPS INTENDED USE TYPE OF WELL P EM AREA CONSTRUCTION 5 IONS 171 Industrial ❑ Open Bottom 1-1MantecaDia. f e Excavation Dia. of Well Casing IJ Domestic/Private C1 Gravel Pack El Tracy. y f Casing Specifications ❑ Public ❑ Other eta Depth of G711,nstalle eal Type of Grout ❑ Irrigation �4pprox_[3 th ❑ Eastern Surface Se Repair Work Done ❑ T e-6f Pump H.P. State one Well Destruction Well Diameter Sealing Material Itop 1 Depth Filler Material (Below 50') t TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic stem ermiti ? P Y P public sewer is -available within 200.feet.) Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms { W 4 Character of soil to a depth of 3 feet: * Water table depth SEPTIC TANK ❑ Type/Mfgj Capacity_____L_ No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal i 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 ❑ Depths t( Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ jr E 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 signatu 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." j The applicant c for all requ're spectiohs/Complete drawing on reverse side. y � 5 Signed Title: Date: FOR DEPA TMENT USE ONLY Application Accepted by ? Date Area t/3 Pit or Grout Inspection by r Date Final Inspection by Date3/4597 45 t. t Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3611 ❑ Manteca Mf7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk.; CA 95201 .L FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. + EH13-24 4REV,1/85) � ` �� -�5/g � I i EH 14-26 '1 �