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APPLICATION FOR PERMIT b SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ` Job Address � I�JG ity /V Lot Size T }e, 1¢!K_ PM 77 Owner's Name� YCl�I� .�JAL_� 41W� Address 'r✓ � / _ Phone Y or Contractor 6Addres 2A _License N_o._,&_0y_16Phone.-� TYPE OF WELL/PUMP: ' NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION I SYSTEM REPAIR ❑ 0TH El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -� DISPOSAL FLD.LaPROP. LINE FOUNDATION _ AGRICULTURE WELL i2toOTHER WELL PITS/SUMPS' t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION `/ l ❑ Industrial Open Bottom ❑ Manteca Dia. of.Well Excavation 1 Dia: Of Well Casio b r XDomestic/Private ravel Pack ❑ Tracy Type of Casing Specifications 4 � fl Public F1�Otrer � C1 Delta Depth of Grout Seal �� Type of Grout�� I Irrigation ISL-Approx. Depth I I Eastern )Surface Seal Installed by 4` Repair Work Done ❑ Type of Pump H.P, / State Work Done t Well Destruction 11 Well Diameter Sealing Material (top.50') r Depth Filler Material (Below 50') q , 9 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTION f I (No septic system permitted if public sewer is available within 200 feet.) k Installation will serve: Residence L Commercial— Other 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 r Distance to nearest: Well Foundation Property Line t r LEACHING LINE ❑ No. & Length of lines Total length/size f FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that t 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. 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, I shall employ persons subject to workman's compensa- tion laws of California." d The applican all ra ctions. Complete drawing on rev a side. Signed X Title: Date: l , �,FOfi DEPARTMENT US ONLY l Application Accepted by Date Area Pit rGwut In n byto Final Inspection by Date Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621 El 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 CK if INFO AMOUNT DUE AMOUNT REMITTED GASH �� RECEIVED BY DATE PERMI7'NO. +.EH13-24{qEV.s/85) EH 14-2e ! � "