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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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 20710 North Oak Street City Acam O Lot Size .12,500sg,ft. PM San Joaquin County Owner's Name Public Works Department Address 1810 East Hazelton Avenue - Phone 944-2281 Contractor Address License No. Phone 3 a- TY—PE OF WELT./PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ® Test Hole 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 T ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 4�r ❑ Domestic/Private X Gravel Pack ❑ Tracy Type of Casing Specifications Attached f N Public Cl Other ❑ Delta' Depth of Grout Seal Type of Grout I I Irrigation 600-!---Approx. Depth I I Eastern Surface Seal installed by 4 Repair Work Done ❑ Type of Pump' H,P. State Work Done_ p Well Destruction. ❑ Well Diameter Sealing Material (top 50') Depth *? Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I'i REPAIR/ADDITION i I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) ' Installation ation will serve: Residence_ Commercial_ Other — is 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. ❑ Method of Disposal jy 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 r M SEEPAGE PITS i I Depth Size Number An 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 F 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 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hi►ing 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. ' Signed X �� Title: Director of Public Works Date: 09/21./87 4 i FOR DEPARTMENT USE ONLY i Application Accepted by Area Date 2 II( ��T Pit or Grout Inspection by Date Fin:Inspection byDate Additional Comments: y f ❑ Stk 466-6781 ❑ Lodi 369-3621 D Manteca 823-7104 ❑ Tracy 835-6385 Applicant'- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 - r FEEK 1 INFO AMOUNT RUE AMOUNT REMITTED C 99 RECEIVED By DATE PERMIT'NO. + EH 13-24(REV.tin5) EH 14-26 ©.�] 1-7f�