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APPLICATION FOR PERMIT 4■ SAN JOAQUIN LOCAL''HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 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'Health District. Job Addressy � �§ '` City Lot Size PM I� Owner's Name bf " = Addressds Phone Contractor''/SfT>F 13Addressr� 'X License N J Phone' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1:1 DESTRUCTION❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER,❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL',"' PITS/SUMPS k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia."-of Well Excavation Dia.;of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ` Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout k Cl Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by I Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Materia! (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet) Installation will serve: Residence_1/ Cmaommercial_f Other t d +r _.....P. o r n Number of living units:�_ Nb tuber of bedrooms Character of soil to a depth of 3 feet: _- iPl1! Water table depth SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments ` PKG. TREATMENT PLT. El of Disposal' a1 Distance to nearest: Well Foundation Property Line LEACHING LINE WL�No. &.Le AN of lines Tota! length/size—ax c FILTER BED d❑ Distance to nearest: Well A00 Foundation Property Line;fid s SEEPAGE PITS ❑ Depth t' Size Number 4%. 41- 1 SUMPS ❑ Dist'ce to nearest: Well Foundation Property Line DISPOSAL PONDS E❑ 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 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 applic us a forre ui d inspections. Complete drawing on reverse side. r Signe Title' �� Date:17 � �, f FOR p TMENT USE ONLY li Application-Accepted,by Date Area �� n Pit or Grout Inspection by f V Date{ Final Inspection by cl/� Date,,5� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369=3621. ❑ Manteca 823-7104 ❑ Tracy 835-6385 �Q cit 90' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. x-2009, BoStk., CA 96201 INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT`NO. .. +EH"18-241REV.1/85) EH 14-28 -.