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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON CA' q Telephone (2091 r�"✓�`f-37 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Tripk3te) 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. IIH Job Address a .�. T ,1 1 City FsG� Lot Size 9@ i aO$� PM r . L-P-A&bes-m Address Phone Owner's Name ��ODEA C Phone Contractor Address License No. _ i TYPE OF WELL/PUMP: i` NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP NEW 12SYSTEM REPAIR ❑ OTHER 171 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION f AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS p Dia. of Well Excavation Dia. of Well Casing Industrial ❑ Open Bottom ❑ Manteca l 5 ecifications k ❑ Domestic/Private ❑ gavel Pack ❑ Tracy Type of Casing p 4C� k C-1 Other l_l Delta Depth of Grout Seal Type of Grout f'1 Public `` C �• ` 1 1 Irrigation _'�I1.Approx. Depth 1 1 Eastern Surface Seal Installed by D Repair Work Done ❑ TypH P. State Work one e of Pump � . Well Destruction ❑ Well Diameter Sealing Material (top 501 rJ Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is 1I11 available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: . Water table depth Number of bedrooms V Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ! Method of Disposal PKG. TREATMENT PLT. ❑ 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 C ! SEEPAGE PITS I I 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 I 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." Contractors 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 call for all required inspections. Complete drawing on reverse side. I V Signed X Title: Y Date: A/ FOR ARTMENT USE ONLY i o Date ` —� Area Applic Accepted by Date��1�°�`t Pit Grout spection by I'' Date Final Inspec' by Additional Comments: .:I ❑ 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, Silk., CA 95201 I � FEE - AIV'IOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO v a.EH 13.24(REV.1/85) �.� ��V �s �.� � �� 1X7 EH 14-26