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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I' 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. Cit Lot Size PM Job Address z c.n- r Y r� 96- rc7 Owner's Name�'� Address 3�f Phone C 4 Contractor ? p1 , ddress I � l �cr— Ql�-�Lic nse No. Phane&3_�;___ 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing V-Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'1 Public n Other ❑ Delta Depth of Grout Sea] Type of Grout I I Irrigation --Approx. Depth 11 Eastern I5urface Seal Installed by Repair Work Pane ❑ Type of Pump r H.P. ICY State Work Dane t ry Well Destruction ❑ Well Diameter Sealing Material (top 50') V 1 = r Depth Filler Material (Below 501 TYPE OF SEPTIC WORK:' NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is ^ I `, , available within 200 feet.I— `( J Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms 1 Character of soil to a'depth of 3 feet: Water table depth,, i-_'• lE IOC SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments,. PKG. TREATMENT PLT..-C1 Method of Disposal f ` -AUG ' — Distance to nearest: Well Foundation Property Line tri u I f't 2 1989 LEACHING LINE ❑ .No. & Length of lines Total length/size FILTER BED 1 �r ❑ 'Distance to nearest: Well Foundation Property Line SERI/iIT/SERVICEP �l SEEPAGE PITS i I Depth ' Size Number SUMPS ❑ Distance to nearest: Well Foundation"' ' Property Line n 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 D%trict. 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." � The applicant must e.60 all required i ons. Complete drawingfon reverse side. Signed X Titles Date: + QR PEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date' n Additional Comments: I ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ..EH 1324(REV.t i H 5) Eµ14-28