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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 I ' _ (Complete in,Triplicate),; ro 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 c 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. I '/_ 4 M&—#72&—#72 15",- Job Address� i �' � ' � - City Lot Size PM D IItL Owner's Name �+p Address � C16 A Phone �� r Contractor At! Address cense NJ_ �sPhone TYPE OF WELL/PUMP: NEW WE L WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATIO / SYSTEM REPAIR ❑ OT ❑ .1• DISTANCE TO NEAREST:'SEPTIC TAN SEWER LINES DISPOSAL FI-11-0 PROP. LINE 2S al FOUNDATION AGRICULTURE WELL'yU OTHER WELL PITS/SUMPS T } INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC T C III ❑ In strial ❑Ope ttom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing omestic/Private a ravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other 11 Delta Depth of Grout Sea! Type of Grout rigation Approx. Depth ❑ Eastern Surface Seal Installed by 1' Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence Commercial_ Other r:f Number of living units: Number of bedrooms Character of soil to a dept9 of 3 feet: Water table depth ( SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 'Distance to nearest: Well Foundation Property Line t, LEACHING LINE ❑ No. & Length of lines ` Total length/size FILTER BED ❑ '#'Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ i Depth Size Number SUMPS ❑ 'Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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. v 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,1 shall employ persons subject to workman's compensa- tion laws of California." a i The applicant ust call for all required i pections. Co late drawing on reverse side. f Signed Title: Dat FOR DEPARTP qNT USE ONLY fy Application Accepted by Date v y Area /IlePit or Grout Inspection b Date Final Inspection by Date �� Additional Comments: Q Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M Applicant Return all copies;to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK* RECEIVED BY DATE PERMIT NO. INFO CASH i /��Sto �b-933 + EH 13-24(REV.1/85)