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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 ' a... (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 Vii_ �1__- � !_if City S"i"mCf`IOOALot Size PM ` M Owner's Name Address �,�/ �d.�ef ffOq Phone "/inis- Contractor s% g l le ' Address (?-. License No. Phone t TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT-E] 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 PRO8L M,AREA CONSTRUCTION SPECIFICATIONS EE` ❑ Industrial ❑ Open Bottom` ❑ Manteca_.---- Dia: of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pa/ht Tracy `Type of Casing Specifications f"1 Public ❑ OtherDelta Depth of Grout Seal Type of Grout I I Irrigation Approx. Eastern Surface Seal Installed byRepair Work Done ❑ Type of PumH.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l i DESTRUCTIO (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence'—A Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3•feeV Water table depth SEPTIC TANK Ll Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT. U k,. Method of Disposal Distance to nearest: Well S Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line N Y SEEPAGE PITS I 1 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 f 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 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- J tion laws of California." !1 The applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: Date: i FOR DEPARTMENT USE ONLY Application Accepted by � Date --2—/G-9Z... Area s is p Pit or Grout Inspection by Date Final Inspection by Date 0 �, Additional Comments: 11 ❑ 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 95201FEE i INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. by � EH 19.28 1AEV.1/85) 3