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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE,, STOCKTON, CA Telephone (209) 456-6781 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. Job Address 3! C_ (Z P --P city I /f .44 V one Owners Name D0't1 d-U� L ePhone �( 3 I Contractor's Name No."?S �-�� - --- - - Phone l! TYPE OF WELL/PUMP: NEW WELL iJ WELL REPLACEMENT J' DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION _ AGRICULTURE WELL _ OTHER WELL PITS/SUMPS ,7, INTENDED USE CTYPE OF WELL-",-PROBL'EM-AREA"' "CONST -RUCTION SPECIFICATIONS ❑ Industrial : p Open Bottom C Manteca I Dia.I of Well Excavation _ _ _Dia. of Well Casing F1 Domestic/ Private 'Ll Gravel Pack C Tracy ;� Type of Casing_.._ _ Specifications L' Public ❑Other � Delta- _!;; ,s,, Depth of Grout Seal :Type of Grout C Irrigation � t' Approx.`Depth n Eastern Surface Seal Installed by., Repair Work Done ❑'� Type of Pump State Work Done Well Destruction C Well Diameter Sealing Material (top 50 t Depth . -T _ Filler -Material iBelow 50') TYPE OF SEPTIC WORK. NEWINSTAL'LATION ❑' "REPAIR/ADDITdON ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within.200 feet,}�� Installation.-will-serve:-,Resldence -k:!::�r-CoVfff T�ial'n— . Other`"-` 7 Number of .living units: Number of bedrooms__ Character of soil to a depth of t -feet.---- 11 Cx Water table depth SEPTIC TANK {T a/.Mf — "'". yf' g.` r l Capacity__ No. Compartments PKG. TREATMENT PLT. ❑ <r FMethod of Disposal Distance to nearest: Well F'i dafion / � Property Line LEACHING LINE No. & L-ength•Af lines'' . mid. F�7. Total length/size FILTER BED 71 -Distance to'nearest: Well Foundation s"� Property Line _ -7-- SEEPAGE `--SEEPAGE PITS 1` ❑ Depth Size ' Number SUMPS Distance to nearesv'- Well l�Foundation�'-Property Line DISPOSAL PONDS C - . i-1 cuy --'y ❑l 1 flavu plepartru A115 application ano tnat the worK will be done in accordance with San Joaquin' county ordinances, state laws, and t rules and regulations of the San JoaquiniLoeal Health District. Home owner or_licensed agent's signature certifies the folbwing:� l_certdy-that-in the-performanceof 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 Callfornia." Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the, work for which this 0ennit is issued, I shall empbypersons subject to workman's compensa- tion laws of California.".,, r �.:.:'v. < ` t The applicant must call for II requ ed inspections. Complete drawing on reverse side/------ -� Signed X__� L�-� Title:- i lfrur'"e.0 �' Date: FOR DEPARTMENT USE ONLY Appy cation Accepted by Date �'F5 Area _,0-7 Pit or Grout Inspection by Date Final Inspection by _ Date Additional Comments: + ❑ Stk 466-6781 ' ❑ Lodi 369-3621 U Manteca; 823-7104 ❑ Tracy 835.6365 Applicant - Return all copies to: Environmental Health Permlt{/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 55201 1 - EH 13.24 IREY, 10/89 EH 14-28 FEE INFO J AMOUNT DUE - - AMOUtJT REMITTED - CK --CASH _r RECELV.ED�y P-._.-. _ �_ _DA.T,E� , __ PERMWISIO.- gS 43 J