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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE I ON 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 Rules and Regulations of the San Joaquin Local Health District. Job Address �� ' l City Lot Size rG PM Owner's Name �Q Address Phone Contractor AL ffr r'. ._. Address Y f n �,�..`rt_License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION.❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (� ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications { 1' ❑ 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 (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Reidence v Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: o 6 JL Water table depth SEPTIC TANK ❑ Type/Mfg 14 L L OA,Co r'�e� ..__ Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ ' Method of isposal Distance to nearest: Wel Foundation Property Line � LEACHING LINE M No. & Length of lines ^�j 14 Tgtal length/size FILTER BED F ❑ Distance to nearest: Well Foundation_.. .. Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line f . 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 h rules and regulations of the San Joaquin Local Health District. U 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, 1 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." i The applicant must cal for all required inspections. Complete drawing on reverse side. Signed X—U,& rfA_' Title: Dater F EPARTMENT USE ONLY Application Accepted by Date r� d 7 Area ' Pit or Grout Inspection by Date p Final Inspection by Date3—/��7 Additional Comments: N �✓�7 �/ lr „_, ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED' CASH RECEIVED BY DATE PERMIT NO. + EH 13-241REV.1/85) �D `� EH 14.28 }