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fov'00- APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1R 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. 1.862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 1 Job Address A ® !� � City ` Lot Size 2 D VROPM Owner's Name — z ! �5 Address Phone Contractor 1hWt TBV�L , Address fucense No.93o=qPhone -_TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 L1 Industrial O Open Bottom �❑ Manteca Dia. of.Well Excavation ' Dia. of Well Casing" ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications V� (1 Public ❑ Other H Delta Depth of Grout Seat Type of Grout �44 I I IrrigationApprox. Depth It Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50' TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION ( l�ff p..septic system permitted if public sewer is I r - available within 200 feet.) Installation will serve: Residence_ Commercial Other i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth—.- SEPTIC epth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ k Method of Disposal Distance to Clearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size "I FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size { Number SUMPS ❑ Distance to nearest:b Well Foundation Property Line DISPOSAL PONDS ❑ +K Y i ! hereby certify that I have prepared this application and.that the work will be done in accofdance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. r 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 rco lesthe 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 la f Califor The applica st call r all require inslActions. Complete drawing on verse side. Si¢n Title: + Date: _X R DEPARTMENT USE ONLY Application Accepted byDate Area d Pit or Grout Inspection by Date Final Inspection by a Date Additional Comments: ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.'Hazelton Ave., P.O. Bdx 2009, Stk., CA 95201 i INFO FEE AMOUNT DUE K 4 AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO.' + EH 14.21/REV.liH5Y J g�3� A' �', 32- EH 11-29 � V ./VLX.J sl