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r r` I g APPLICATION FOR.PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6761 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. f � Job Address �� City Lot Size PM Owner's Name '� Addresss.. Phone ' Contractor's Namebyo e 1 License No. J 7A Phone 6p I r TYPE OF WELL/PUMP: 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 a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation *'Dia. of Well Casing ❑'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top-50') t Depth Filler Material 16elow 50') TYPE OF SEPTIC WORK:' NEW INSTALLATION Jd—REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is } available within 200 feet.) f` Installation will serve: Residence Commercial_ Other Number of living units: _A__ Number of bedrooms -? 01y Character of soil to a depth of 3 feet: Water table depth f� SEPTIC TANK Type/Mfg 444 - Capacitylj_aZ f No. Compartments !_ PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line �Q r � LEACHING LINE ANO. & Length of lines �.9�40I Total length/size FILTER BED ❑ Distance to nearest: Well � Foundation� Property Line r SEEPAGE PITS M9 _Depth 2Y t -S ize '36 e -"W Number 1� SUMPS 0 Distance to nearest: Well Foundation c� Property.Line DISPOSAL PONDS ❑ A hereby certify that I have prepared this application and that the w6rk 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 th peperformanca 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-comperGation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work#or which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." M The applicant mustcall o a required inspections. Complete drawing o1 reverse side. Signed Title: Date: /91 r � r FOR EPARTMENT USE ONLY V I Application Accepted by Aa Date 7- 2 Area / Pit Grout Inspection by ate Final Inspection by ate �5 — 4V Additional Comments: Ok ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Y .- FEE AMOUNT DUE AMOUNT REMITTED CK 0 RECEIVED BY DATE PERMIT'NO. INFO /� CASH + EH 13.24(REV.10/83) L S, a� --J�/�C� �3 �s �t EH 1428 r �s