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i APPLICATION FOR PERMIT ( ` \�/ O SAN JOAQUIN LOCAL HEALTH DISTRICT Q � y 1601 E. HAZEL T ON,AVE., STOCKTON, CA r Telephone (209) 466-6781 J PERMIT EXPIRES TYEAR FROM DATE ISSUED KAU" \\\ (Complete in Triplicate) ENVIR0ME19TALv► -C/SE CES N►1 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereA�Rscribed. 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 ` " –> City LI^[tI� Lot Size PM Owner's Name %'rmQ ,4�lAfBdress � a��Y Phone X--5 -,21 Contractol L� S Address KFC )C I `T License No. 2 3 Phone 6 6 z 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ _. I I Irrigation _..Approx. Depth�,I I Eastern Surface Seal Installed by __ W Repair Work Done Et-- Type of Pump � H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 ` s Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (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 Character of soil to a depth of 3 feet: `Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I I Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property;Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line 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 rules and regulations of the San Joaquin Local Health Di$trict. Home owner or ' nsed is signatlu8 certifies the-fol 'ng:"t certify that in the performance of the work for which this permit is issued, I shall not employ any son in such nner as to become subjec o orkman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies th ollowing: "1 ce f ha4ine or an �eworor which this permit is issued, I shall employ persons subject to workman's compensa- tion laws f Ca ornia."The ap icant t cal r II requ ng on revSigned ritle: Date: �^ 90 F PARTMENT USE ONLY 7 Application Accepted by Date— l Area Pit or Grout Inspection by Date 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 INFO AMOUNT DUE AMOUNT REMITTED CASH CK 9 RECEIVED BY DATES PERMIT'NO. r.EH 13-241REV.1/95) ►'-- EH 14-26 v v