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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA p Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora 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. p, � ate✓ C +� 1!!f`C Cit Lot Size /�J X / /PM Job Address 66012' �' F c^Y Owner's Name /l<L 0 .e� AW10Y2J Address / c.+ • /�� Zf�� o/� Phone /d ^Q/ Contractor li�� Address License No. Phone_ E OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAR EPTIC TANK SEWER LINES DISPOSAL-FLD. - PROP. LINE _ FOUN AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL EM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack El-Tracy f:Type hinge- - Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Se _ Type of Grout—,_, I I Irrigation —Approx. Depth . I I Eastern 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 Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11--REPAIR/ADDITION l.1 DESTRUCTION)<(No septic system permitted if public sewer is r _, available within 200 feet.) \J� Installation will serve: Residence Commercial_ Other ,r Number of living units: Number of bedrooms. Character of soil to a depth of 3 feet:, Water table depth SEPTIC TANK El Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal " Distance to nearest: Well Foundation 9 Property Line LEACHING LINE ❑ No. & Length of lines ) Total length/size -° -- FILTER BED ❑ Distance to nearest: Well Foundabori Property Line SEEPAGE PITS 1-1 Depth Size Number r SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f. 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: '9 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." 9 The applic t mut caljfok all-required i pections. Complete drawing on reverse side. n 0- Signed X Title: ' —°^ ° Date: 6 FOR DEPARTMENT USE ONLY10 _ Application Accepted by Date r�Z/ Area Pit or Grout Inspection by Date Final Inspection by Date v Additional Comments: �r�V�'l�1 ltir r l tJ ❑ Stk 466-6781 ❑ Lodi 369-3621 O 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 IFEE NFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. + EH 13-24(REV.1 i 9 5) EH 14-26