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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. i S�StI� r r Job Address City &--01- Lot Size PM Owner's Name Address Phone Contractor i / r? e�� Address ; -2;7 �Lic_ense No. l9 Phone l TYPE 4F WELL/PU P: NEW WELL ❑ WELL REPLACEMENT ED) 0 `DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTE6-`RE6lRwp---- , OTHER ❑ ' DISTANCE TO NEAREST: SEPTIC TANK• T------ - S-EWER^L-INES-- =-"L- DISPOSAL FLD. PROP. LINE FOUNDATIOiJ, AGRICULTURE WELL OTHER kl-L PiTS/SUMPS _ INTEW&6 USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation` 3 Dia. of Well Casing, ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of.Casing -� Specifications El Public ❑ Delta ❑ Other � Depth of Grout Seal ''� � Type of Grout ❑ Irrigation -__Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done Ll Type of Pumps' H.P. � State Work Doge r Well Destruction ❑ Well Diameter' Sealing Material [top501 Depth ;j •*:Filler Material (Belowl50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DtS,TRUCTION ❑ (No septic system permitted'if public sewer is �� available within 200 feet.) Installation will serve: Residence�,Commercial Other Number of living units: --,Z— Number of bedrooms _ ' Character of soil to a depth of 3 feet: O. + Water table depth •-. rt JZCD� SEPTIC TANK ❑ Type/Mfg06A/ Ca pacity No. Compartments PKG. TREATMENT PLT. 71p ! �-._- /�ne i Method of Disposal Distance to snearest: Well Foundation-1-(5_ P%perty Line _ ! LEACHING LINE $Z No. & Length of lines ._e-1 I i •r`� ^ Total length/size �. FILTER BED ❑ Distance to nearest: Well Foundation Property Line f f SEEPAGE PITS ;Z Depth Size Number .G ✓s Lr� SUMPS ❑ Distance tog nearest: WeilFoundation DISPOSAL PONDS El Pr°party Line.:" I hereby certify that I have prepared this application and that the work will be done in accordance with San1Joaquin 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 employan permit is issued, I shall not i y 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 com tion laws of Califo _— w pensa The applicant u call for quir spections. Complete drawing on reverse side. # Signed Title: Date: J FQR.QEPARTMENT USE ONLY f1 Application Accepted by Date q — b ' r Area Pit Q ?Grout Inspection --- by Date -- c Final Inspection by Date L 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 AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERMIT'NO. + EH 24 1REV.7/95)W - b EH 14-28 C), 1 .