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� y)a-)v / APPLICATION FOR PERMIT " lr(� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 well/pump and the Ryles and Regulations of the San Joaquin Local Health District. i �• Job Address � � C ' City P�)— Lot Size "'"` PM Owner's Name ,i�DD$/�� Address r Phone Contractor A AddressLicense No,.:;2�J `J Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout p ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by W Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 C�1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONDESTRUCTION El (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence ��Commercial_ Other Number of living units:I Number of bedrooms,'? Character of soil to a depth of 3 feet: �S.Jl9�D� 4&AM Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal �p Distance to nearest: Well, Foundation Property Line LEACHING LINE ❑ No Qkength of lines Total length/sae FILTER BED Distance to nearest: Well Foundation Property Line N0. ri SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 have prepared.this application and that the work will be done in accordance v4th San°Joaquin co un tyl.ordinances, state laws, and C rules and regulations of the Safi Joaquin Local Health District. ' 3 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 sha11 employ persons subject to workman's compensa- tion laws of California." The applicant must call r all r' ired i tions. Complete drawing on reverse side. Signed Title: �,. Date: FOR DEPARTMENT USE ONLY Application Accepted by �—�' Date Area J3 Pit or Grout Inspection by Date Final Inspection by ' Date I— 9effV Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 anteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to:.Environmental-Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520] FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT"NO. INFO CASH +EH 13-241REV.1/85) EH 14.26