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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT CL,,� 1601 E. HAZEL T ON AVE., STOCKTON, CA r� VJ Telephone (209) 466-67$1 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is he+eby 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! 712 /! t 0C City r Lot Size PM Owner's Name n �/'fU " Address 27•Qe VEL T - � Phone 4 Contractor +v Address rf �� 'J` License No14+��Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR F3' 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 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack_ 0 Tracy_ Type of.Casing Specifications * Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout Irrigation --Approx. Depl,4 I 1 Eastern Surf ce l Installed by - Repair Work Done 2r' Type of Pump H,P. SeaState Work Dome IV Well Destruction ❑ Weil Diameter Sealing Material jtop 50'1 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION i I; DESTRUCTION i I (No septic system permitted if public sewer is ; k available within 200 feet.) tIJ Installation will serve: Residence— Commercial= 0th Number of living units: Number of bedrooms' P Character of soil to a depth of 3 feet: r , Water table depth ' SEPTIC TANK - ❑' Type/Mfg "'° Capacity No. Compartments PKG. TREATMENT PLT. ❑ _ Method of Disposal Distance to nearest: Well: Foundation Property Line LEACHING LINE ❑ No. & Length of lines " Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS I 1 Depth Size F _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I' 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"Sari-Joaquin-Lccal'Health DisTfict. " -_j 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 f£elifornia." j The applica must call fo all equired ins p ons. Complete drawing on reverse side. 1 Signed X _ Title: _ Date: 3 -3 !II FOR DEPARTMENT USE ONLY I Application Accepted by Date Area Pit or Grout Inspection _ _ Date Final Inspection by Date Additional Comments; -( �!c-tw.�Ct/t 1�/ Uy, 1 y 3�c Vil d i _ III ❑ Stk 466-6781 D Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385 Applicant . Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. CASH +EH 53-24 IAEV.1/85) W 14-2e • Q