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APPLICATION FOR PERMIT SAN JOAQUIN`LOCALwHEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA " Telephone 1209? 466-6781 PERMIT EXPIRES 1,'YEAR FROM' DATE ISSUED'' i �k {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. 186'1 for well/pump and the Rules aria'Regulations of the San Joaquin Local Health District. 'X't . . { 10 r . . , k, C .va„ Nl ; f� 9 1 ski F yti / `' •,� /1 ��rti ? ` i:! City 40 Lot Size PM Joh Address `` , Owner's Name 14 r�Vcldress -5-9ASS �. Phone �� ✓�f � -4 6R--f C tractor l �� - " ' CAddress Z Q � f 1. Lt[��4 License No.• Phoneg 1 c f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION P< SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE Y FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Ria. of Well Casing XDomestic/Private C71Gravel Packr ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Dept_N ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump �°� H.P. State Work Done Well Destruction ❑ Well Diameter. Sealing Material {top 501 j Depth i Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 6 r available within 200 feet.) Installation will serve- Residence—C Commercial_ Other Number of living units. Number of bedrooms ' 4 1 Character of soil to a depth of 3'feet: Water table depth O SEPTIC TANK'S ❑ Type/Mfg Capacity No. Compartments ' PKG. TREATMENT PLT. ❑ Method of Disposal;} . RAfDistance to nearest:. Well Foundation Property Line - LEACHING-LINE, ElNo`& Length of lines Total length/size 31i x 4 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS � '`:�'�� `Depth}S�`� �, r� Size Number SUMPS _ El Distance-to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 end regulations of the San Joaquin Local Health District. Homeowner d icensed 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 call f all ret} 'r inspections. Complete drawing'ona erse s1 t f Signed Title:1 � Ad 70 Date: F R DEPARTMENT USE ONLY � Application Accepted by DateWW� Area Pit or Grout Inspection by ' Date Final Inspection by Date •� E 'Additional,Comments. ❑ Stk 466-6781 ❑ Lodi 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 IFEE NFO AMOUNT DUE AMOUNT REMITTED ASHD-- RECEIVED BY.. DATE PERMIT`NO. a EH 13-241REV.1/85) - a. ' •► k � � - /g 05�S j . ' EH 14-28