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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL TON AVE., STOCKTON, CA Telephone 1209) 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. r Me Cit Lot Size PM _ € Job Address y Owner's Name Address Phone Contracto ' Address6,, /;P, License No.3 A -2 Z PhoneAW 74 7 _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION LJ "SYSTEM REPAIR ❑ OTHER 0 DISTANCE.TO NEAREST: SEPTIC-TANK, SEWER LINES. DISPOSAL FLD. :PROP.vLINE• �-o- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS + ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f-I Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout - ._ Q I I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50')_'.__. Depth Filler-Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l l QLA1.5JADDtTION 1J DESTRUCTION I 1 (No septic system permitted if public sewer is l available within 200 feet-1 Installation will serve: Residence__,X. Commercial_ ther $ Number of living units: Number�`oi bedrooms Character of soil to a depth of 3 feet: [ — Water table depth SU : SEPTIC TANK ❑ Type/Mfg € Capacity No. Compartments PKG. TREATMENT PLT. ❑ ti Method of Disposal Distance to nearest: Well" Foundation Property Line LEACHING LINE Lal No. & Length ofllinees ~ Total length/size 9d' }� FILTER BED ❑ Distance to nearest: Well 5 Foundation_7K/_1__ Property Line SEEPAGE PITS I I Depth Size Number SUMPS L7 Distance to nearest: Well "Eoundation 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 and regulations of the San Joaquin Local Health Di%trict. 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 - -F=-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." r -- -The-applicant mu -call for all req it d inspections. Complete drawing on reverse side. G C Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted I ' Date � Area / k �1+ Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 i ❑ 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 i FEE AMOUNT DUE AMOUNT.REMITTED CK RECEIVED By DATE PERMIT"NO. INFO +.EH 13-241REV-1/85) 1_26s V o 6a/s pV V60 EH 14-26 f }