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p APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT AT 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 Rules and Regulations of the San Joaquin Local Health District. Job Address :; 70.7 1 City Lot Size PM e 1�/�`/^>' Address / �- Owner's Name � Phone ^ Contractor /�� '/ -/Address N /�r // License No.��✓ �f�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 1 ❑.Domestic/Private ❑ Gravel Pack ❑ Tracy Type ofCasing - — Specifications l'1 Public ❑ Other n Delta Depth of Grout Seal" ""'"moi � Type of Grout I I Ifrigalion . —.-Approx. Depth l I EasternSurface Seal Installed by _ Repair Work Done 0 Type of Pump H.P., State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material I8elow,50') r TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION ( DESTRUCTION_11 (No septic system permitted if public sewer is 4 available within 200 feet.) U Installation will serve: Residence`� Commercial— Other Number of living units: . Number of bedrooms Character of sail to a depth of 3 feet: Zaam; # } Water table depth SEPTIC TANK ElType/Mfg ,4".0 Capacity AZB No. Compartments V ' i' PKG. TREATMENT PLT. ❑ T r Method of Disposal Distance to nearest: Well�— Foundation Property Line LEACHING LINE ❑ No. & Length of lines `_ Total lengthlsize Q a a +: FILTER BED El Distance to nearest: Well�'l. � Foundation " _.y. Property Line SEEPAGE PITS I 1 Depth Size T Number. SUMPS D Distance to nearest: Well Foundations Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that'the work wilt be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. v 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 Iaws.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 subjectto workman's compensa- tion laws of California." ; The applicant must call for all required inspections. Complete drawing on revs a side/ l/��r �( Signed XIII x AI�J�. 1l YJr�" Title: Date: U r ROR DARTM NTIJE ONL•Y', Y •- Application Accepted by' = Da[e� r `F y r Aea Pit or Grout Inspection by '; D to Final Inspection by OwAfDate Additional Comments: '- Cl Stk 466-6781 ElLodi 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 CK 9 CASH RECEIVED BY DATE PERMIT'NO. ♦ EH13-24.IREV,1/85) EH 14-28 ♦ •/