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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA r '1 Telephone (209) 466-6781 !� Y 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 3 r City / Lot Size PM Owner's Name %Je� r.rS i Address Phone r Contractor •� G Address ;P,12i �� e!!!!e�License No.a22,-y_�, 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 mow~ INTENDED USE��T TYPE WCL LL 1; 08LEM AREA—CONSTRUCTfON SPECIFICATI0N57` ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing � 4 -I ❑ Domestic/Private ❑ Gravel Pack,��--�---i�Tracy;,��- Type of Casing Specifications "1 Public 11 Other Fl Delta Depth of Grout Seal Type of Grout-- _ I I Irrigation _.-Approx. Depth I I Eastern Surface SedInstalled by _ Repair Work Done ❑ Type of Pump __' - H,P. State Work Done r Well Destruction ❑ Welf Diameter Sealing Material ]top 501 .t. 1 Depth ; ' Filler Material {Below 501 _ TYPE OF.SFPTIC WORKa'`NEW,INSTALLATION REPAIR/ADDITIQN t„1 DESTRUCTION l I°-.tNo septic system permitted if public sewer is ' 1 available within 200 feet.) Installation will serve: Residence 2_$�' Commercial,__ Other ..� �w._. �. _� _,.• _:.��-__+:a --— ---- _--- '- s�•� � � Nrillib�raf7rvrng-u?SrTs �lUumber of tredrooms _,- Character of-soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity._ No. Compartments PKG. TREATMENT PLT. ❑ ,_ �►� .7— Method of Disposal Distance to nearest: Well Foundation Property Linel"� LEACHING LINE No. & Length_of.lines �� Total length/size FILTER BED ❑ Distance to nearest: :W6`11—10" Property Line r SEEPAGE PITS I I Depth Siie �� x�� Numbar �. SUMPS 1 �^ Distance to nearest: Well; oundation - Property'�Line r 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 s rules and regulations of the San Joaquin Local Health Di-Mrict. 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 must call for all required inspections. Complete drawing on reverse side. 1 Signed X - Title: 0GDate: ✓�� /' a'`� t , • 11`01 DEPARTMENT USE ONLY , Application Accepted by Date /..;J// tArea "` Pit or Grout Inspection by ^' ; 3 l Sig Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant% Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE ,/AM0UNT._REM1T rED_ �,-CK — RECEIVED'BY" DATE -PERMiT NO. n INFO- - CASH { ' +.EH"11241REV."1/85) --.. - - -�•� �w.r.5.ra.,..-�...�, 1/� ! O �... EH 14-2e / r