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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZEL T ON AVE., STOCKTON, CA ` I Telephone (209) 466-6781. f . .: s . 1 r" I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APP lication 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 Ipump and the Rules and Regulations of the San Joaquin Local Health District. II 111 a� _. Job Address f- City / --� ` � of Size �' � PM Owner's Name .5 �l / Address Phone Contractor s- �` M Address /� l/�`�" ' License No. �6pPhone TYPE OF WELL/PUMP: -�A'NEWyWELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP"INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO,NEAREST: SEPTIC TAI-410, SEWER LINES DISPOSAL FLD. PROP. LINE 3 FOUNDATION- AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OFIVfrL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ' ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gtave),P.ackhe :it ❑ Tracy z 'Type of-Casing Specifications i � +�,: �• 4 3 I ❑ Public ❑etr �L; ; f❑ Delta' ,y depth.f,Grout Seal \Type of Grout i N ❑ irrigation Approx. Depth ❑ Eastern;r " Surface,Seal Installed by Repair Work Done ❑ Type of Pump r. Hep. ' State Work Done Well Destruction © -Well Diameter i ': 1 Sealing Material (top 50'1 1 t� Depth `"Filier Material (Below 50'1 '"4 (� TYPE OF SEPTIC WORK: NEW INSTALLATION.3 REPAIR/ADDITION DESTRUCTION ❑-(No septic system permitted if public sewer is available within 200 feet.) a Installation will-serve: Residence• Commercial ther r " Number of living units: �l Number of bedrooms Character of soil to a-,depth of 3 feet: �' __ Water table depth 1 SEPTIC TANK ❑ Type/Mfg ; Capacity. . No. Compartments r ` P•KG'. TREATMENT PLT- ❑ ` w t �~ Method of Disposal r Distance to nearest: --Well � �'�Founi99tion ° .. -Property Line p. LEACHING LINE &r No. &"Length of lines ;fFs Total length/size is FILTER-BED--- - -- ❑ Distance to nearest: Well Foundation Property Line lip SEEPAGE PITS ❑ Depth Size Number i SUMPS ` r Distance toilearesr" Weil Foundation 2� 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)air 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 workmen's compensa- tion laws of"California." The applicant must all require inspections. Complete drawing on reverse side. Signed Title: [�,��' c�� I Date: _�Z—/2 - Signed FOR DEP TMENT USE ONLY I . Application Accepted by I Date v ' Area Pit or Grout Inspection by Pate 1 '"'` Final Inspection by Date e-/ IM Additional Comments: _ O-Stk- 466=6761._.._'--❑'Lodi"369'3521"`•`i--❑-IUlanieca "823-710__4x ❑ Trac'y__9 5-6385- Applicant - Return all copies to: Environmental Heal_th.Permit/"Services 1601 E. Hazelton.Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT`NO. + EH 13-24(REV.s/85) EH 14-28 <