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.f= •'l: ; APPLICATION FOR PERMIT "' ' i A SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ..�} Telephone {209} 466-6781 r PERMIT >=XPIRES 1 YEAR FROM DATE ISSUED ?l5 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for herein pppermit to construct and/or install the work herein descrrbed�f h1s ton 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, f r �a kA�, e Job Address 1 �!I r7 (1 _ City SE46t Size PM ' {j{ Owner's Namep� 1 Y'aG3 �tQl�l;s� tt f c�n f) Phone Contractor �t. t Address (J License No. Phone TYPE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP FOUNDATION AGRICULTURE WELL OTHER WELL ITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEC ON5 ❑ Industrial Q Open Bottom ❑ Manteca Dia. ofWe vation Dia. of Well Casing " r ❑ Domestic/Private ❑ Gravel.Pack:. ❑ Tracy a of Casing Specifications FI Public ❑ Other R Depth of Grout Seal Type of Grout I I Irrigation __Appy I I Eastern Surface Seal Installed by Repair Work Done a of Pump "`�H.P. State Work Done Well Destr on ❑ Well Diameter Sealing Material (top 501 n Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLAT16N I I REPAIR/ADDITION I I DESTRUCTION iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence—4 Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depP of 3 feet: f ` Water table depth SEPTIC TANK Type/Mfg. Capacity_2No. Compartments PKG. TREATMENT PLT. ❑ t - Method of Disposal 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 i I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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. _,r ,_ :._. 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."-Contractor's 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: U:�Dg-f- Date: `a FOR DEPARTMENT USE ONLY Application Accepted by Date 1 5' Area Pit or Grout Inspection-lb Date Final Inspection by Date Additional Comments: �$ 1!16-42 ❑ Stk 466-6781 ❑ L i 3 -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant Return all copies to: Environntal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK KSH RECEIVED BY DATE PERMIT NO. ♦ E0113-241REV.1/85Y � EH 14.26 `L