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1-17rV APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-Ml PERMIT EXPIRES 't 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. f Job Address 1j, CityS Lot SizePM Owner's Name CA�t"Paf Address "► Phone Contract ' ddress Dd 7! d License Na: t- i Phone,36efn s-1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER.CI 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 SPECIFICATIONS4 f� ' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of V ell G:asing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seat Installed by f Repair Work Done `❑ Type of Pump H.P,c State Work Done Well Destruction ❑ Well Diameter Sealing Ma 'at.(top 50') DepthMaterial eIRW 50'► TYPE OF SEPTIC WORK: NEW INSTALLATION❑ EPAIRDDITION DESTRbeT4QN (No septic s m permitted'rf public sewer is rtrt �' �200 feet.), Installation will serve: Re idenceCommercial Other Number of living units: Number o§bedrooms` Character of soil to a depth of 3 feet: Water-table depth S SEPTIC TANK ❑ Type/Mfg Capacity No. Cbmpartmenw PKG. TREATMENT PLT. ❑ r' Metlled,of Disposal Distance to nearest: Well Foundation _ Property Line LEACHING LINE LST No. & Length of lines 4 , Total length/size - FILTER BED ❑ Distance to nearest: Well _ Foundation . .Property Ole r SEEPAGE PITS `Depth Size /�� _ �D Number` SUMPS ❑ Distance to nearest: Well Foundation f Prooii t Line. _ DISPOSAL PONDS ❑ hereby certify that t have prepared this application and that the work will:be done in accord9i5t yrith.;Sattft `uhr'coufi'ty 0 Inances'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 subcontracting signature certifies the following:"I certify that in the performance of the work for which this permit ii Issued,I shall employ persona subject to workman's companies- tion laws of California." The applicantvust call for ui inspections. Complete drawing on reverse side. Signed Title: y ' .` Date: FOR DE TMENT E(INL3l- Application Accepted by Date �Y13 Area Pit or Grout Inspection by Date Final Inspection by Date . Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3135-3621 ❑ Manteca 823-7104 ❑Tracy 835,6385 Applicant- Return all copies to Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box ZOOS, Stk., CA 96201 INFO AMOUNT DUE' AMOUNT`REMITTED GASH RECEIVED BY d D "i #�ERMIT"N0. }EH 13.21(REV.t/95) EN 14-28