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I�S APPLICATION FOR PERMIT SAN JOAaUIN LOCAL HEALTH DISTRICT 1 1601 E. HAZELTON AVE., STOCKTON, CA E Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROWDATE'ISSUED °z (Complete in Triplicate) f`` a 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. u r . k' Job Address 1,Cc- 45_,&23 r Q r a. City�' ��7�1�_'Lot Size ply Owner's Name LEA/ _ Address Phone Contractor . ) Address /00- License No. Phone TYPE OF WELL/PUMP: {. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ \A PUMP,INSTALLATION ❑ -•--SYSTEM-REPAIR 0— .—•- - OTHER❑ i' DISTACE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. ?ROP. LINE FOUNDATION AGRICULTURE'WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE,OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia:of Well Excavation I _ Dia. of Well Casing C7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ! ❑ Public ❑ Other ❑ Delta Depth of Grout Seal \ _,f , P Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done El Type of Pump I H.P'. State Work Done 'e Well Destruction ❑ Well Diameter':. Sealing Material {top 50'1 Depths I I Filler Materia!`(Below 501r l TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No 'septic system permitted if public sewer is availh6le within'.206_feet. Installation will serve: Residence 7! Commercial Other Number of living units: Numbe))))r of bedrooms! Character of soil to a depth of 3 feet- SEPTIC Water table depth SEPTIC TANK T e/M _ - i. YP opacity_ �,. No. Compartments PKG. TREATMENT PLT, ❑ If .`,a$`t - ofDisposal "� I Method t '� Distance to,nearest: Well Foundation— Line .- is ?' I f IL-EA'CHiNG-tINE—O--No7&'Length-of-lines_ "`-`s Total length/size FILTER BED ❑ Distance to'nearesr Well Foundation Property Line - J° SEEPAGE PITS ❑,_,,Depth_ . !Size �"- t tNumber �` I SUMPS } ❑ Distance to near sf "" Vi/e11 Foundation ;Property Line ' I j DISPOSAL PONDS ❑ - --_ .I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordjnances3state laws, and rules and regulations of the San Joaquin Local Health District. ! I 1 1 1 Home owner or licensed agents signatureic�ertifies the following: "I certify that in the performance of the work for which thisspermit is issued, I shall not employ any person in sucsuch manner as to become subject to workman's compensation laws of California."Contractas hiring or sub contracting signature certifies the following:"I certify that in the performance of the work for wAch'this permit is issued, I silo)l employ persons subject to workman's compensa- tion laws of California." y i The applicant t call for all req uir d inspectio . Complete drawing on reverse side. } � t i . Signed Title: '7 -,t Date: sal I � FOR—DEPARTMENT—USE—ONLY"'"""°""� f, _ Application Accepted by Date Area ©� 1 1 -/ Pit or Grout Inspection b Date Final Inspection by r i Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 E El Manteca 823-7144 ❑ Tracy 835-6385 3 e I Applicant-Return all copies to: Envlronme t I Health Permit/Services 16th E.'Hazelton Ave., P.O. Box 240$ Stk., CA 952011 ' - --- - CK FEEAMOUNT DUE �� AMOUNT. CASH RECEIVED BY DATE PERMIT_No. INFO +EH-13-24(REV,1/85) EH 14-26 �'�,�, T ., .. _-