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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRI 1601 E. HAZELTON AVE., STOCKTON, C i , 'f irr Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEPAN J'OAQUIN LOCAL - ' (Complete in Triplicate) HEALTH DISTRICT 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. 1962 for well/pump and the Rules and RegulatiorAof the San Joaquin Local Health District. Job Address City !h ,07 Lot Size PM Owner's Name p�co Address r �� ^/�7 �p� Phone' ^—r Contractor's Name w p� No. ,Iq_ . �z Phone J TYPE OF WELL/PUMP: NEW WELL )k- WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ _ DISTANCET�NE4RJ 51: 5'EP C TANK SE1M1l1 R LINESDISPOSAL FLD- PROP. LINE FOUNDATION AGRICULTURE WELL OTHER'.WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ?eDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth-of Grout Seals a Type of Grout ❑ Irrigation ---Approx. Depth ❑-Ea tern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. `y State Work one Ad Well Destruction ❑ Well Diameter Sealing Material Itop 501 . Depth Filler Material Melow 501 S 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_ Commercial_ Other 1'1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: - Water table depth SEPTIC TANK ❑ Type/Mfg �y Capacity No. Compartments PKG.TREATMENT PLT. ❑ _ �•�f� Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well foundation Property Line E _ SEEPAGE PITS ❑ _.Depths _.Size SUMPS ❑ Distance to nearest: Well Foundation Property Line t DISPOSAL PONDS ❑ r 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 4 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 P certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of California." The applicant must cal for all r ired i pectin omplete drawing on reverse side. 9 I Signed Title: �f/GZ�yi O Date: / Q I FOR DEPARTMENT USE ONLY Application A,_cceptadL by D,ate Pit or Gro t Inspection by Date Final Inspection by Date Additional Comments: t ❑ Stk 466-6781, ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83 6395 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �r<�` 9 3— td DUE AMOUNT RI MITTED CK RECEIVED BY DATE PERMIT'NO. ,...Y,[!EAMOUNT _ CASH p . + EH 13-2419tV.10/83)EH%26