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APPLICATION FOR PERMIT SAN JOAO.UIN LOCAL HEALTH DISTRICT ' J t 1601 E. HAZEL T ON AVE., STOCKTON, CA IA AY 1 li9B7 r Telephone (209) 466-6781 w PERMIT EXPIRES 1'YEAR FROM DATE ISSUED ENVIRONAENTAL HEALTH (Complete in Triplicate) FERMIT/SERVICES 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 Na.549 for sewage or No. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address � City Lot Size PM Owner's Name � r Address Phone ps f Contractor / -j Address /' License No. Phone Z— 1 TYPE OF WELL/PUMP: t NEW WELL ❑ WELL REPLACEMENT ❑, DESTRUCTION ❑ PUMP INSTALLATION 2PRr,0417e ,r4GYSTEM REPAIR ❑" � OTHER ❑ � DISTANCE TO NEAREST:- SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL "`` b PITS/SUMPS ' INTENDED USE t TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �� 4 71 industrial 171 Open Bottom ❑ Manteca Dia. ofTWel4 Excavation Dia. of Well Casing A�76omestic/Private Q Grave! Pack ❑ Tracy Typeof`Casinggf rj Specifications I ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ' ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by 9 Repair Work Done ❑ Type of Pump H.P. State Work DoneEf7fJ�C Well Destruction ❑ Well.Diameter �Z _Sealing Material Itop 501 1,� Depth y•' Filler.Material"IBelow.50;1' ' ' *�` Y a.� 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 Number of living;units:, Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Wel! Foundation Property Line ' SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: . Well Foundation Property Line t r N ��•- 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` rules and regulations of the San Joaquin Local Health District. I Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit i6 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- tion laws of California." � I The applicant mu t cal for II requ inspections. Complete drawing on rave side. I Signed X � T Title: �� Date: 7-L' ?7 jZIOR DEPARTMENT USE ONLY Application Accepted by Date1/45" Area Pit or Grout Inspection by Date Final inspection by Date v 1 Additional Comments: ❑ 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' D�iUEI' AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH13.241REV.1/85) EH 14-28 J '