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' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �y 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 C, 40 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 Local Health District.tL2M Job Address [A��City (� Lot Size /7'��l PM Owner's NameZ.. Address �33 Soc di CA Phone 3b 0 lZ0 �j Contractor's Name U O• License No. 1�.L5y L Phone 7 Z7_ 5 TYPE OF WELL/PUMP: NEW WELLN WELL REPLACEMENTS DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ,r n $EWE'R LINES -PROP. LINE FOUNDATION 7�4 AGRICULTURE WELL i OTHER--WELL- S-5' PITS/SUMPS L5D -f- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial )6Zbpen Bottom ❑ Manteca Dia. of Well Excavation 2 a Dia. of Well Casing Z 1>6omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing cS'�ee �. Specifications . /Z$wa 1\ �/ ❑ Public El Other El Delta Depth of Grou`t66eal So Type of Grout S /O S El Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by wo _S S ;9i r Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 ,r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will serve: Residence_ Commercial_ Other available within 200 feet.) � Number of living units: Number of bedrooms A Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/MfgCapacity No. Compartments PKG. TREATMENT PLT. ElMethod 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 SEEPAGE PITS ❑ Depth Size Number v: 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 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- tion laws of California." The applicant mlist.call for all required inspecti s. Complete drawing on reverse side. Signed X Title: Date: Z FOR DEPARTMENT USE ONLY i Application Accepted by Date \of Area Pit or rout Inspection Pe b Y Date/::;_I � YFinal Inspection by to 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 AM OUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT NO. IN CASH + EH 13-24(REV.10/83) EH 14-26 �Z7 � '�9