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APPLICATION FOR PERMIT 4 SAN JOAQUIN LOCAL HEALTH DISTRICT + 1601 E. HAZEL T ON AVE., STOCKTON, CA / 0-1 Telephone 4209) 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 Ryles and Regulations of the San Joaquin .-,Local Local Health District. Job Address Rd - City Lot Size z.Z `Owner's Name Address C�/�d �j�'�- C� Tr Phone Contractor - Address F y� License No.} Phone f TYPE OF WELL/PUMP: NEW WELL f WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION�1 SYSTEM REPAIR ❑ OTHER ❑ i .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �.� DISPOSAL FLDe'�? f_ PROP. LINE FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ ?,,,trial �p Open Bottom ❑ Manteca Di�of Well Excavation Jomestic/Private ❑ Gravel Pack ❑ Trac T Dia. of Well CasingY yof Casing d cifications j" ❑ Public EJ Other - El Delta Depth of Grout Seal Type of Grout- ---Approx. ❑ Irrigation Depth ❑ Eastern w w Surface Seal Installed by Repair Work Done ElType of Pump ff0a H.P. �.. ' /( \� e, State Wor Done W i Well Destruction ❑ Well DiameterSealing Material (top 50') Ce- Depth e Depth Filler Material (Below 50')- TYPE OF SEPTIC WORK: NEW INSTALLATION ❑"REPAIR/-ADDITION ❑ -DESTRUCTION EI'(No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial i Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ' }} SEPTIC TANK ❑ Type/Mfg *k Capacity No. Compartments f PKG. TREATMENT PLT. ❑ Method of Disposal Distance to Well Foundation Property Line , LEACHING LINE ❑ No.`& Length of linesTotal length/size 'k f FILTER BED ❑ µDistance to nearest: Well Foundation Property.Line. i ~ SEEPAGE PITS * ) ❑ Depth Size SUMPS- .b Number ❑ , Distance to nearest: Wefh Foundation Property Line DISPOSAL PONDS ❑ - 1 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. F Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work far 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." r S The applicant ucall for all require ' spectio s. Complete drawing on reverse side. - Signed Title: Date: FOR DEPAR ENT USE ONLY -""Application Accepted by— —Da—Da :� j� s ' te Area'r a IAL Pit or rou inspection by bate ' Final-Inspection by Date Additional Comments: El Stk 466-6781 Lodi 369-3621 El Manteca 823 7104 LJ Tracy 835 6385 Applicant Return all opies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED 1 INFO CASH RECEIVED BY DATE PERMIT"NO. +Eli 14-26 EH 13-24(REV.1/95) •—� pJ f` r 3