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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 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 Rules and Regulations of the San Joaquin Local Health District. A / Job Address / U 6 r City Lot Size F PM Owner's Name Address �• "°'-'� /_ �..�/ Phonal +, Contractor s License No. Phone TYPE OF WEL IPU P: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑ , PUMP INSTALLATION © SYSTEM REPAIR ElOTHER \ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL PROP. LINE FOUNDATION AGRICULTURE WELL OT ELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONST N SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca . of Wall Excavation Dia. of Well Casing Ll Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ a Depth of Grout Seal Type of Grout ❑ Irrigation ____Approx. De ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of P p H.P. State Work Done Well Destruction ❑ iameter Sealing Material {top 501 Depth Filler Material (Below 501 TY E OF TIC WORK: NEW INSTALLgTION REPAIR/ADDITION L7 DESTRUCTION ❑ (No septic system permitted if public sewer is -lr�// available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units:__V_ Number of bedrooms Character of soil to a depth of 3 feet: /� ,p Water table depth SEPTIC TANK ElType/Mfg Capacity s6 1/ No. Compartments PKG. TREATMENT PLT, ❑ r Method of Di s sal Distance to nearest: Well Foundation /dO Property Line LEACHING LINE ❑ No. & Length of lines _ Tgtal length/size % FILTER BED ❑ Distance to nearest: Well.9Foundation 9 6 Property Line SEEPAGE PITS ❑ Depth;.X1GX/, Size Number MP ❑ Distance to nearest: WallffO Foundation—I 07 Property Line DISPOSAL PONDS ❑ 1 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 applicant ust call fora quir ctions. Comp to rawing on rse side. ' Signed X G Title: Date: Date: FOR DEPARTMENT USE ONLY 2 , Application Accepted by Date r A i �1__ Pit or Grout Inspection by Date Final Inspection b Date 4- Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M .r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P. . Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMITNO. + EH 13-241REV.1/85] —7 P6—1 EH W28 G�O _I