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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 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. Jab Address L y� � City� Lot Size ° 3 PM Owner's Name _ U Address es Phone ContractorL C✓ r_ INU. 6ddress-3-50 w V icense No.� O %4_Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 C DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ^' I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELD, PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing { ❑ Domestic/Private ❑ Grave,Pack ❑ Tracy Type of Casing Specifications ❑ Public `1 ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ` Approx. Depth ❑ Eastern Surface Seal Installed by ( R_pair.Work;Done} ,❑!! Type of Pump H.P. State Work Done 't r` Well Destruction ❑ 'Well Diameter Sealing 1Mater01 (top 50'T__ Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION t_DC3TIRUCTION-❑l septic system permitted if public sewer is � `,.* available within 200 feet.) F Installation will serve: Residence_�mmercial Other. r. 4 i Number of living units: Number of be rooms ! r e -- J Character of soil to a depth of 3 feet: - �� > Water table depth SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT. ❑ ' r Me hod of Disposal " 'a i 'y' f' t1Distance to nearest: Well.. Foundation Property Line LEACHING LINE r._- 9-24" Length of Imes 1``�' Total length/size FILTER BED d Distance to nearest: Well%C�i.� Foundation Property Line SEEPAGE PITS Q Depth Size ` Number SUMPS N-6istence to nearest: Well � Foundation k4O_ Property Line +. DISPOSAL PONDS ❑ SU Thereby certify that I have prepared this application and that the-work will be done in accordance with San Joaquin 1county 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, I shall not f a loy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature a caro' s the following: 1 c fy that in the performance of the work for which this permi6s issued, I shall employ persons subject to workman's compensa-tion la f California." r The applica us all for all quired ' specti G let ,awing o averse si �� , Signed { Title:~ Date: r — j ��-•-�>u "� �'F ,/��L(X,bD..T�TjVK'!S Gle�?'�R«4fit� FOR DEPARTMENT USE ONLY STS rte- i-jJp� U Application Accepted b Date Area Pit or Grout Inspection by Date " Final Inspection by Date Additional Comments: A"' ❑ Stk 466-6781 ❑ Dodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE �-AMOUNT.DUE _ _ .AMOUNT REMITTED CASH -RECEIVED 9Y'" — - DATE"' —4" PERMIT'NO. INFO 4' + EH13-241REV,1/85) EH 1 -28 r �