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ff APPLICATION FOR PERMIT 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. / /) City Lot Size PM Job Address 4 *� l� 1 F� Ar Phone �� Ownerlls Name` – Address Contract r ' Address .or License No. �a`�' Phone g�s I as TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑- DESTRUCTION ❑ PUMP INSTALLATION-0. SYSTEMREPAIR ❑ –OTHER.-D. .. �... ._ / ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL L OTHER WELL PITS/SUMPS �" 4 INTENDED USE TYPE OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � _Dia. Well Casing...Dia._ofWe11-Excavation. _O.Industrial ❑_Open.Bottom LI.-Manteca . I' ❑ Domestic/Private LJ Gravel Pack ❑ Tracy Type of'Casing - Specifications f'l Public {1 Other ❑ Delta Depth of Grout Seal Type of Grout f A rox. Depth 11 Eastern Surface Seal Installed by ° � I I,Irrigation Pp P Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth er Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l l EPAIR ADDITION DESTRUCTION l I (Nosepticsystem permitted if public sewer is available within 200 feet.) r ,rte installation will serve: Residence Commercial Other Number of living units: _J_ Number f edroo 's - Character of soil to a depth of 3 feel: _ r Water table depth -SEPTIC TANK © Type/Mfg Capacity No. Compartments F PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines Notal length/size A w t " FILTER BED 11 Distance to nearest: well FoutS'�tiori 10r Property�iye 4 1 lf' SEEPAGE PITS ls�Depth Size Ir _tNumber lSUMPS Ll Distance to nearest: Well-�00— Foundation s C Propertrty Line M .r DISPOSAL PONDS ❑ t 1 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 n^ rules and regulations of the San Joaquin Local Health District. i 1 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,actig shall not i employ any person in such manner as Ito 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 com_pensa- tion laws of California." The applican st call for qu'ed inspections. Complete drawing on reverse Ida. i Q - L Signed Title: Date: i r FOR DEPARTMENT USE ONLY 1 '� Date Area/ / — ! Application Accepted by �( Pit or Grout Inspection by Flit Inspection Additional Comments: ( 1:1Stk 466-6781 D Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385 ®� Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 ®� I _ CK 0 FEE AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT NO. INFO ! + EH 13-241r1EV.1/95) AA *� �,C�b C V•� 1 fir[ J- fs-ffV vi a EH 14-26 111