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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.;•STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED I4 ,� ' .IComplete in',Triplicate} t �+ M 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. Job Address �� .�r p "1`' Ave� City Lot Size C 1� PM Owner's Name Address Phone Contractor (A 1s f Address_ 7. Licens_e_Nor �� 3 _ Phone �'a- , TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION —SYSTEM-REPAIR ❑ OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK 1 t D SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTU RE!WELL- } OTHER WELL PITS/SUMPS \ INTENDED t1SE TYPE OF WELL, PROBLEM AREA CONSTRUCTION SPECIFICATIONS , ❑ Industrial XOpen Bottom'` ❑ Manteca Dia. of Well Excavation 1'�. Dia. of Well Casing Domestic/Private ❑ Gravel Pack ;_ Cl Tracy Type of Casing Specifications ❑ Public ❑ Other "' ❑ Delta a'�t Depth of Grout Seal JS t Type of Grout r CC,,.e, ❑ Irrigation' _— pprox. Depth ❑ Eastern': rtace Seal Installed by LI Repair Work Done LlS Type of Pump im H.P.. �-_ _ State Work Done Well Destruction' ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') ` TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is .r available-within 200 feet.) { r Installation,will serve: Residence— Commercial_ Oth r ''t{ i Number of living units:. - Number of bedrooms t Character of sail to a depth of 3 feet: Water table depth ' SEPTIC TANK ❑ Type/Mfg - Capacity (INo. Compartments ; * Disposal Dis of PKG. TREATMENT PLT. ❑ Method� �� P Distance to nearest: Well Foundation Property Line lj j LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED- f rs❑, 'Distance to nearest: Well Foundation Property Line SEEPAGE PITS KOC Depih — Size Number_ - + SUMPS ❑ "Di11stance to nearest: Well Foundation Property Line 't DISPOSAL PONDS ❑ s 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 work4or 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:"Contractors hiring orsub contracting signature certifies the following:"I certify that in the performance of the work for which this permit issued,I shall employ persons subject to workman's compensa- tion laws of California." f The applicant mat call for all required inspections. Complete drawing on reverse side. � � t } Signed )( �,r_ fel/J41LJLaJC�ic9 T� Title: e ��d Date: i FOR DEPARTMENT USE ONLY Application Accepted by Date ✓�E^ Area — Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: F ❑ Stk x 46&6781 -- ❑ Lodi--369-3621 ❑ Manteca W 823-7104—0-Tracy^8354M Applicant- Return all copies to: Environmental Health Permit/Services31601'E.-Hazelton Ave., P.O. Box 2009, Stk., CA 95201 , FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT''NO. INFO {�{} CASH �1 + EH 13-241REV.1/85l �a � ' - -1 �V EH 14-26