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APPLICATION FOR PERMIT .A SAN JOAQUIN LOCAL HEALTH DISTRICT -� 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 �y PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Y17 (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 City —��a� Lot Size PM Owner's Name Address I Q S 5 C.f-7T- � C(4-6—.� (p Phone Contractor Address License No. Phone 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public El Other El 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 Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units:_� Number of bedrooms Character of soil to a depth of 3 feet: _ _ Water table depth SEPTIC TAMC ❑ Type/Mfgg cr No. Compartments PKG. TREATMENT PLT. ❑ - Method of Disposal Distance to nftwit rVR, I1y-haVa-,.eX06@dt.W1th[]1.1�...� Property Line LEACHING LINE CE] No. & Leng bfi eg I L1l Total length/size FILTER BED ❑ Distance to n"YE'dr., viro�l �isifln Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ - 1 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. I- 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 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." li ' The applicant must call for all wired in pections Complete drawing on reverse,slde. Signed Title: �60 Date: FOR DEPARTMENT USE ONLY ^� Application Accepted by - Date ?,3 U�� / Are Pit or Grout Inspection ,� (VI-s Pe Date Final Inspectio Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P. . ., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT`NO. CASH INFO J + EH 1&24(REV.t/95) /5� 13!x` �j y� [}� y EH 14-28 �,/��JJ LL// J / V'-�(/ d