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' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE;TON AVE., STOCKTON, CA • ` Telephone (209) 466-6781 .�' 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 well/pump and the Rules and R �ns of the Swann Joaquin Local Health District. r�,1 lry Job Address` " v City Lot Size / PM 1 e s Owner's Name Address Phone U Contractor ss I ense No. Phone TYPE OF WELL/PUK4P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREACONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 4 '1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout _ M I I Irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by r Repair Work Done L-1Type of'Pump H.P. State Work Dane Well Destruction ❑ Well Diameter Sealing Material Itop 50't Depth Filler Material(Below 501 Q TYPE OF SEPTIC WORK: NEW INSTALLATION T REPAIR/ADDITION l 1 DESTRUCTION l I INo septicsystempermitted if public sewer is available within 200 feet.) ry ` Installation will serve: Res'dence L Commercial__Other V i Number of living units: Number of bedrooms :1 i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg fu Capacity No. Compartments PKG. TREATMENT PLT. ❑ ,Q r Method of Disposal Distance to nearest: Well/_00 Foundation L(— — Property Line 1 i LEACHING LINE ❑ No. & Length of lines Tot I length/size FILTER BED ❑ Distance to nearest: We1I�t�—Foundation - Property Line SEEPAGE PITS I I Depth X 0 S e Number SUMPS LlDistance to nearest: Wel! Foundation _.(QrZ Property Line _...._ ISPOSAL PONDS ❑ f l 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 l rules and regulations of the San Joaquin Local Health District. J , 6 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 I I req " d i spectlons. to drawingon �TwA4,6efx= side. Signed Title: Date: FOR DEPARTMENT USE ONLY 1 Application Accepted by Date A,.i Pit or Grout Inspection by Dat Final Inspection by Date 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.Q. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 4f CASH RECEIVED BY DATE PERMIT N0. } +.EH 13-24 IREV.1/85) EH 14-26 2