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II r. �.,.. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT j t 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 SEP ::7 19$g PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) CNVIMNMENRALHEALTH PERM11'ISgRy1C�3 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. is app,kation 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 Sah Joaquin Local Health District. Job Address City of Size PM Owner's Name .eitQ D A'l -� ' "" Address Phone Contractor Address T BJ`�� a _-?License No. Phone TYPE OF WELL/PUMP: NEW WELL L7 WELL REPLACEMENTfi❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ - DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE y FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ! INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial C7 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ("I Public ❑ Other f-1 Delta Depth of Grout Seal Type of Grout I I Irrigation --.Approx. Depth I I 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 50') _ :TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK_ EJType/Mfg `_-Capacity ' _,No. Compartments PKG. TREATMENT PLT'❑ + �- Method of Disposal z Distance to nearest: Well Foundation ..Property Line LEACHING LINE 17-1 No. & Length of lines Total length/size FILTER BED 0—Distanc-o nearest: Well 'Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS ❑ Distance to nearest: Well `Foundation Property Line DISPOSAL PONDS ❑ s 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 note ; 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." The applicant m II or all require inspections. Complete drawing on,r verse side. ' Signed X— �str Title: _ ��1 Dater R DEPARTMENT USE ONLY Application Accepted by Date S � /`,� Pit or Grout Inspection by Date Final Inspection by _ 1�to H I l Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 El 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 -,;—CAS v. RECEIVED BY DATE PERMIT"NO. ; ♦.EH 13-2q IriEv.sixaJ EH tq-2a