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r � APPLICATION FOR PERMIT ��" _ �a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-67$1 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. D ¢/ _ Job Address / [� �( �-.tf�' � City vi/ Lot Size 7e PM Owner's Name Address SAW"" Phone -3 Contractor's Name License No. _200wdl hone T S O9 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 017S/SUMPS 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 ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501• Depth '� Filler,Material IBelow 50) 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_Z Commercial_ Other ; Number of living units: _d__ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK OType/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ` x r ;� Method of Disposal Distance to nearest: Well - O Foundation t /0 Property Line LEACHING LINE No. & Length of lines S Total length/size �7C FILTER BED ❑ Distance to nearest: Well a(22/_ Foundation f5 f` Property Line /tr5' 1 x SEEPAGE PITS 1 Depth -�27 Size 36 Number i SUMPS ❑ Distance to nearest: Well�A&Z7/ Foundation- Property Line 112r> DISPOSAL PONDS Cl 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 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 must c or all requ' i ciions. Complete drawing on rev rse sine. Signed F T. Title: Dater FOR DEPAICTMENT USE ONLY ,( Application Accepted by Date 1L2�y� Ar4at, Pit or Grout Inspection by " Date 'w` �` Final Inspection by __ ��//� f Additional Comments: ❑ Stk 466-6781 t Lodi 369-3621 ❑ Manteca - 104 ❑ Tracy 83&6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 --------------- FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. INFO CA514 +EH 1324(REV.10!83! EH 1LA 428