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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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.Tics 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 Z4e City Lot Size a"'" PM Owner's Name, �E•c•- Address T_< y� /�' ` �� Phone Contractor's Name License No. �a CS 7� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ d 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of,Pump H.P. State Work Done t Well Destruction ❑ Well Diameter Sealing Material (top 501 + Q Depth Filler Material (Below 50') ' TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION DESTRUCTION ❑ Mo septic system permitted if public sewer is available within 200 feet.) Z Installation will serve: Residence ti Commercial_ Other hrnee__ T Number of living units: Number of bqprooms ` r Character of soil to a depth of 3 feet: �--'� � Water table depth / d SEPTIC TANK fxYType/Mfg e �a Capacity /.2, T-& No. Compartments - PKG. TREATMENT PLT. ❑ Method of'Disposal j t Distance to nearest: Well r Foundation Property Line0 � LEACHING LINE & Length of lines jVo Total length/size 4;/4 r FILTER BED Distance to nearest: ? Well 4t •`Foundation t Property Line qty X, SEEPAGE PITS Q'—Depth Sizer. Number r .SUMPS ❑ Distance to nearest::-- Well_J4f5_-_ Foundation 645 r Property Line 2d � � DISPOSAL PONDS ❑ i hereby certify that I 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 li8ensetl 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."Contractors 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." The applicant must call f all r aired inspections. Complete drawing on reverse side. Signed X _. Y M Title: dML Date: WOW FOR DEPARTMENT USE ONLY Application Accepted by Date TL Area f P�' dr Grout Inspection by ate Inspection by ��/� �9� Date Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t. r 1. I t INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT"N0. +EH 13-24(REV.10/83E EH 1426 ,a 1 �3C/8 �y`;t.• ,IS