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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 (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 I/p p and the Rules and Regulations of the San Joaquin Local Health District. 01 ] f_Ll 7 7 Job Address 1 �^' /tc'. City Lot Size 1 PMv Owner's Name Address 12— 01E /" Phone /' S Contractor a4zAddress d J License No. T o Phone 0 / 2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYST REPAIR L1 OTHER O DISTANCE TO NEAREST: SEPTIC TANK SEWER LI ES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICUL R ELL OTHER WELL PITS/SUMPS f INTENDED USE TYPE OF WELL PROBLEM AREA ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F]l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation _.Approx. Depth l I Easter Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler terial (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION fr REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial 7 \Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: v Water table depth SEPTIC TANK ❑ Type/Mfg Capacity 12-00 No. Compartments PKG. TREATMENT PLT. ❑ rr Method of Disp al Distance to nearest: Well—V*Foundation Property Line LEACHING LINE ❑ No. & Length of lines 7i K Total length/size d FILTER BED ❑ Distance to nearest: Well A o Foundation AD Property Line SEEPAGE PITS I I Depth ize _ Number SUMPS Ll 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 Diltrict. 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 ust call for allmquired jpspections. Complete drawing on reverse side. Signed X Title: Date: a FOR DEPARTMENT USE ONLY Application Accepted by &<<7 � Date�Z— lCi Area Pit or Grout Inspection by Date Final Inspection by��^ ' Datel 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 DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. a.EH 1 -24(REV.1/85) EH 144-28 V