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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON,. CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED MAR 31 1989 (Complete in Triplicate) E�I,I;i3 f Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the ibi�d2 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. # ��1 Job Address !0 7'-5� LL- 4—& -' {U City Lot Size PM i Owner's Name AddressPhone Contract,3211& a !geg Address P2 Gi 160 1YAA4! ;� oy otf ense No.�� Phone L"3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR O� OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 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 L VDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r l I"1 Public L. Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done (f Type of Pump reds H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION I 1 DESTRUCTION I I {No septic system permitted if public sewer is 00 I1 available within 200 feet.) E T Installation will serve: Residence! Commercial_ Other LA�� Number of living units: NumL Number of bedrooms A Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments k PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Wel! Foundation Property Line LEACHING LINE ❑ No. R Length of lines { Total length/size FILTER BED ❑ Distance'to nearest: Well Foundation Property Line _ � t SEEPAGE PITS ( I Depth Size Number SUMPS ❑ Distance to nearest: Well ^,Foundation Property Line DISPOSAL PONDS 0 L I hereby certify that I have prepared this application and that the work will be d&66 in accordance w4h 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 hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." - .-. ' The applicant rWst call ffr all required inspections. Complete drawing on-reverse side. Signe Title: Dater F R PARTMENT USE ONLY i Application Accepted b — Q PRy Date Area I` Pit or Grout Inspection by Date Final Inspection by Date' t r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 335-6385 Applicant - Return all copies to: EnVironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17'No, EH 13.24 1REV.1/n 5) EH 14-28