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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 456-6781 PERMIT EXPIRES TYEAR 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address —t5-7-79 ' City MV Lot Size PM. Owner's Name Phone V.5 Q r 1 Contractor t?LOIS"" Address I IMQ,k�0 License No. Phone I TYPE OF WELL/PUMP: NEW WELL ❑ WELEIREPLXCEIMENT 0 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ s DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL. FLD. PROP. LINE f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ❑ Indusuial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing © Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r] Public F1Other Cl Delta Depth of Grout Seal Type of Grout r I I Irrigation _.-Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 �^ TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION No septic system permitted if public sewer is available within 200 feet.) I Installation will serve: Residence?—,C- Commercial— -Other— Number of living units: -- Number of bedrooms r Character of soil tc a dep h of 3 feet: Water table depth a SEPTIC TANK' ❑' Type/Mfg —' 'Capacity No. Compartments ` PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of tines Total length/size FILTER BED ❑ Distance to nearest-. Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line .1% DISPOSAL PONDS ❑. € s. t 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 i rules and regulations of the San Joaquin Local Health District. j 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 1 employ any person in such manner as to became 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,1 shall employ personssubject to workman's compensa- tion laws of California." - +^ •^ The applict must c for all required inspections. Complete drawing on reverse side. S '- �5 Signed X Title: �. ._-,,.....-..,.,__ Date: FOR DEPARTMENT USE ONLY r Application Accepted by DatelI Area Pit or Grout Inspection Date Final Inspection by Date Additional Comments: Z�_4C.2. ❑ 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. Bax 2009, Stk., CA 95201 FEE CK INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT�NO. + EH 19-241RE'V.1/1,11 �-In_3�t EH 1426 _1 1 0 1