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W APPLICATION FOR PERMIT P . " SAN JOAQUIN LOCAL HEALTH DISTRICT �� 1 6 4 W 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED (Complete in Triplicate) 005' S' 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 Joao- Local Health District. 9,L( ° r Job Address City Lot Size PM Ra l Owner's Name :f%_ Address Phone _ �,,, _ 1 Contractor's Name License No. y2 — Phone I?—7/3 0 TYPE OF WELL/PUMP: EW WEL ELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTAL I.�,ONN �❑ SYSTEM REPAIR ❑ OTHER ❑ _ DISTANCE TO NEAREST: SEPTIC TANK '— SEWER LINES • -- DISPOSAL FLD._1004 PROP. LINE 1-0 FOUNDATION �� AGRICULTURE WELL _. ,� OTHER WELL ,, PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrialpen Bottom ❑ Manteca Dia.'of Well Excavation Dia. of Well Casing el Roomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I Dg ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout , ❑ Irrigation y --Approx. Depth ❑ Eastern Surface Seal Installed by N 1 Repair Work Done ❑ Type of Pump H.P. State Work Done i Well Destruction ❑ Well Diam Sealing Material p 50'1 Dept Filler Material Below 50'1 TYPE OF SEPTIC WOR t.: 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 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ T e/Mf + Yp g Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line.. f 4 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED F-1Distanceto nearest: Well Foundation Property Line I SEEPAGE PITS ❑ Depth Size Number III j SUMPS ❑ 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 District. 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 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 us call for all required inspection mplete drawing on reverse side. �p SignedTitle: . _ Date: �! F DEPARTME USE ONLY / Application Accepted by Date � Area � Pit o Grou nspection by Datq Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 p 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 11 CASH RECEIVED BY DATE PERMIT'NO. + EH13-24)REV.10/83! EH 1426