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s z APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA (l�� Telephone (209) 466-6781 - `-'IK- , �� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 6-t`Aty�`f\�y\. (Complete in Triplicate) kA`4' { _ 4 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descnbe�d. 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 ' Job Address �.�-2)7 '&kr0� �' ` — City � mot Size PM ` 'C Q f-�XI'C KAddress �5 Q� . rC'J� Phone Owner'sNam�� I Contractor igU IN—qr Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 'DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM-REPAIR +OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP FOUNDATION AGRICULTURE WELL-, -� OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SjwE6+fATIDNS ❑ Industrial ❑ Open Bottom ' ❑ Manteca Dia- of xcavation _ ,Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy W � . ype of Casing ' —Specifications f'1 Public n Other F a Depth of Grout Seal : --.Type-of,Grout. _ I i Irrigation ._Appro�` l 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ of Pump H.P. State Work Done Well Destruc y ❑ Well Diameter ' Sealing Material [top 5011 Depth ----Filler MaterialIB61ow 5011 - R TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTIONY 1No septic system permitted if public sewer is } s` available within 200 feet.) 1' Installation will serve: Residence x Commercial_ Other Number of living units: 2 Nurriber of bedrooms '�2- : Character of soil to a depth of 3 feed Water table depth SEPTIC TANK ❑ Type/Mfg', Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposali Distance to nearest: Well Foundation Property Line 4 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ' Well Foundation Property Line j SEEPAGE PITS I I Depth Size Number SUMPS 1=1 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 and regulations of the San Joaquin Local Health District. 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." t ust call for aill required inspections. Complete drawing on reverse side. s _ Signed Title: a cnf Date: MENT USE ONLY Application Accepted by (DObate l"c ��J� Area Pit or Grout Inspection by Date Final Inspection by Date G/1 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT NO. + _ 3P4 3-24IREV-i/85) 0 L2 P� -EH 1e /--.