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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 04 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' (Complete in Triplicate) 1 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. �J G /�,,o "v` City �� d�� Lot,Size PM N Job Address / ( tAddress Phone Owner's Name Contractor's Name Al/ Phone 1 License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION L1 ` PUMP INSTALLATION ❑ SYSTEM REPAIR ElOTHER El t —� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE K S FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ElIndustrial [1 Open Bottom 11 Manteca Dia. of Well Excavation Dia. f Well Casing ❑ Domestic/Private ❑-Gravel-Pack^- -F=-•-❑-Tracy- —Type-of-Casing �^`-� --` Typcific Grout ❑ Public 13 Other J El Delta Depth of Grout Seal Type of Grou I ❑ Irrigation Approx. Depth ❑ Eastern y Surface Seal Installed by i Repair.Work Done ❑ Type of Pump H.P. ' State Work Done i� Well Destruction ❑ Well Diameter `Sealing Material (top 501 Depth I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION�K-DESTRUCTION ❑ (No septic system permitted if public sewer is I available within 200 feet.)' Installation Mil serve: Residence Commercial Other f Number of living units: Number ofberooms # z 2/f 1 Character of sail to a depih of 3 feet: Water table depth ! Ca aci z4p No. mpartmentss Z SEPTIC TANK �c 'yType/Mfg p PKG. TREATMENT PLT: ❑ t Method of Dipposal Property Line Distance to nearest: Well Foundation Notal length/ t LEACHING LINE 9 No._&Len"gth of lines size FILTERAEb ❑ Distance to nearest: Well fU Foundation tLf7 Property Line SEEPAGE PITS .; ❑ Depth;° Size Number -- d 3. Property Line ) SUMPS Distance to nearest: We11`r, Foundation Y DISPOSAL PONDS ❑ I I hereby certify that'l 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. 1` r Home owner or licensed agent's signature.certifies the following:-"I certify.that-in xhe_performance-of the work-for.which this permit is issued,.1 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 1n 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 app' nt must call for ail required inspections. Complete drawing on reverse side. �L Date: i Signedi - Title: 1 r FOR DEPARTMENT USE ONLY a kr. 1 [� 1 4 1 ._ _Date -y-1 �/ Area Application-Accepted-by_ — Date -Final Inspection by Date p " Pit or Grout Inspection by F Additional Comments:- ❑ Stk 466-8781 ❑ Lodi 369-362 ❑ Manteca 823-7104 ❑ Tracy 835-6365 L Applicant- Return all copies to: Env Ionmental Heaith Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. i INFO P p 4`-E s �� 2 + EH 13-24 IREV-70/83) �✓ / � �� EH 1426