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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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. Job Address /4?�� j ' C/�� City Lot Size Q jX4&&d1PMI ` %d^ 0 Owner's Name Ql—td 4 Address SIAT&Pr A.,re Phone Contractor Address L4e License No.029'Mr—Phone 27'Y.r- TYPE OF WELL/PUMP; NIW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 1104/ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPSti INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing 91 if Domestic/Private Gravel Pack El Tracy Type of Casing Specifications Public ❑ Outer - -❑ Delta Depth of Grout Seal ,V_A---,---*Type of Grou O ❑ Irrigation P4,40—!Approx. Dep�th j Eastern Su ace Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms 4 Character of soil to a depth of 3 feet:' P Water table depth � SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ E Method of Disposal Distance to nearest: Well Foundation Property Line L LEACHING LINE ❑ No. & Length of lines ♦. `' _ Total length/size FILTER BED ❑ Distance to`nearest: _�... WeII�� __� Foundation Property Line SEEPAGE PITS ❑ Depth f Size Number SUMPS ❑ Distance to:nearest: Well Foundation Property Line DISPOSAL PONDS ❑ .7 1 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. X Home owner or licensed agent's signature certifies the following: "I certify that iR 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." {f The applicant must CaA for u' ing on reverse side. 1 f Signed Title: Date: Vby , FORDEPARTMENT USEO LY Application Accepted bJ. `° Date " J AreaPit o Grout I pection Da e Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 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 (NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 13-24(REV,1/65) 1 EH 14-28 O 16-7 3