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APPLICATION FOR PERMIT , t ; SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON 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 r Local Health District. - Job Address City 1 Lot Sized Ply Owner's NamAddress Z g � ? r Phone Contract Address gyp` s License No. Z�� Phone r/O TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR O 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 ❑ 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 . State Work Done_ " Well Destruction Cl Well DiameterSealin Nlateriah{iop 50 f Depth ller Material (Belo -50') 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAI '/ADDITION DESTRUCTION ❑r(No septic system permitted if public sewer is �J F available within 200 feet.) Installation will serve: Residence Commercial_ Other f Number of living units:__L_ Number of,biedrooms _ ! Character of soil to a depth of 3 feet: Water table depth V SEPTIC TANK ❑ Type/Mfg Capacity �No.'Compartments i PKG. TREATMENT PLT .11 D Mett od of Disposal Distance to nearest: Well Foundation"' Property Line } LEACHING LINE IKNo. & Length of lines r y Total length/size FILTER BED ❑ Distance to nearest:" WeFl t Foundation_�� Property Line SEEPAGE PITS Depths Size �E �-.Number SUMPS C7 Distance to nearest: "Well" Foundation l�'� Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be-dohe,in'accordance with San Joaquin county ordinances, state laws, and fi rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:f1 c`ertify 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 f certifies the following: "I certify that in the performance of the,%kork for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." � {^- --— - -- -- The applicant must call+for a equ d inspections Complete drawing on raver s'de. ' Signed X �2'�-1 , 7.(J, Title: !/ T" Date: �Z (YOIX nr, 'FOR DEPARTMENT USE ONLY411 / Application Accepted by Date 19 7__1 Area / ) P'r or Grout inspection by Date , G _�^� _Final-inspection_by - - _-Dat i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 ¢= j."Tracy 83rr638b 1.;ar. � '.� �Applicant_Return-all copies_to: Environmental.-Health_Permit/Services 1601_E._Hazelton-Ave,_R.O.-8ox.2009,-5tk. CA SUM_--.�-_�_ FEE CK t 3 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT'NO. + EH 13.141 REV.1/85) 14 /1 EH 14-28 C7 . ['> 1 /{ `_ f