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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA _ Telephone 1209} 466-6781 ]PERMIT EXPIRES 1 YEAR FROM_D_A_TE 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 °r, Local Health District—, Job Address k_ u �k' !'f WI/ Zi City Lot Size PM ' Owner's Name'' 1i i"y 31(f, D fW_ Addressdd 4e 1J _ Phone l9 7-3—3 f Contract0j, fy- g 1 of W1Lek1(fr Address �F �'l +� S -License<No. Phones �3 TYPE OF WELL/PUMP: NEW WELL-TO WELL REPLACEMENT ❑ DESTRUCTION,❑ PUMP INSTALLATION '0 SYSTEM REPAIR ❑ OTHEFII k j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD:- I,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 it ❑ Domeestic/Private ElGravel-Pack cTracy Type of Casing PAivle -.t*lhho.4 1� Specifications ► i �, ❑ Public ❑ Oche ` ""`"""" Delta Depth of Grout Seal Type of G'cut��f�{,u ❑ Irrigation ---Approx. Depth ❑ Eastern SurfaoeSealtlnstaild-'liy rt ':.% Ra" ��' Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destrrpction ❑ Well Diameter Sealing Material (top 501 • i. yr Depth Filler Material (Below 501 TYPE OF SEPTI ORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION 0 fNo septic system permitted if public sewer is a+�" "le %,.availab'le within 200 feet.) Installation will serve: Residence_ Commercial_ Other i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water tabledepth y SEPTIC TANK ❑ Type/Mfg. f f.. Capacity /Method _ �# PKG. TREATMENT PLT. ❑ Method of Disposal y Distance to,nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines Total length/size 4 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS } '❑ Depth ?; " ; .. Size Numbe*Property { SUMPS ❑. Distance to nearest: Well Foundation Property Line y.DISPOSAL'PONDS C1 ! ,, ';—f-herebycee 4 tt at I have prepared`ttns applicVo-hand-that-the;work will be done in accordance with Sar equin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signator ce er`tifies the following: "I certify that in the performance-of the work for which this permit is issued, I shall not pbject3?o workman's compensation laws of California."Contractor's hiring or sub-contracting signature employ any pe yson in such manner as to become sue certifies the folidwing: "I certify that in the performance of-the work for which this permit is issued,I shall employ persons subject to workman's compensa- J tion laws of California." I The applicant ust call for 711ruiyd in pe ions. Complete drawing on reverse side.Signed .•< �.... i e: � [ 17� r� �©��ff rJ�� ~.Date: !v *. t OR ARTMfNT USE ONLY Application Accepted b Data �` Area ! Pit or Grout Inspection by ; ;A i Date Final Inspection b Date Additionai Comments: El Stk 466-6781 ❑ Lodi 369- ❑ Manteca 823-7104 ❑ Tracy 83540% Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazehon Ave., P.O. Box 2009, Stk., CA 95201 i IFEE NFO AMOUNT DUE AMOUNT REMITTEE C SH RECEIVED BY DATE PERMIT" 0, i a EH13.244REV.1/85l � 3�S- 00 3q 0: .- i�'� l0f - ab ��'�1O EH 14-26 j