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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E-,HAZEi.ON.AVE', STOCKTON, CA Y-- Telephone 12091 466-6781 NOV 19 1984 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQWN LOCA, {Complete in Triplicate} HEALTH MSIR" tion is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. his applies made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 18622 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �7 - Job Address ��° (C✓ City Lot Size is Address � -T '��4 � Phone Owner's Name - _ No. Phone Contractor's Name ense TYPE OF WELL/PUMP: NEW WELL,❑ , r, WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION , SYSTEM REPAIR IJ OTHER ❑ � �.r .?.,?.. DISTANC.E TO NEAREST:,-SEPTIC,TANK. SEWER LINES.w DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ElIndustrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation _ Dia. of Well Casing (S Tomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications El Public ❑ Other ❑ Delta Depth of Grout Seat Type of Grout ❑ Irrigation __-Approx. Depth [DEastern S? ace Seal Installed by / State Work Done .� � Repair Work Done K3' Type of Pump H p Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth Filler Material [Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑.._DESTRUCTION I] .(No septic-system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other i Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: Water table depth_ } SEPTIC TANK E] Type/Mfg Capacity -f .No. Compar3ments hAeihad of Disposal R PKG. TREATMENT PLT. ❑ S Distance to nearest: Well Foundation Property Line LEACHING LINE ElNo. & Length of lines �" M Total length/size FILTER BED ❑ Distance to nearest: Well 7.�Foundation Propertq-tine 1 � j SEEPAGE PITS ❑ .Depth Size ` r Number SUMPS ❑ "Distance to nearest: Well Foundation-= Property Line 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 1� rules and regulations of the San Joaquin Local Health District. ; Home owner icon 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 an person in suc manner as to become subject to workman's compensation laws of California." Contractors hiring or sub contracting signature certifies a following:"I ertify that in the ormance the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion law of California." 4 The app'cant mu 1 r all that - d ' mple drawing on reverse side. &0�', Signed Title: Date: FOR DEPARTMENT USE ONLY it.t - Application Accepted by Date.� 0 7a rte, V^ � ' Date Pit or Grl4 Inspection by Date Final inspection by - 'R Additional C&nments:'°" '- ' ~ ❑ Stk-466-6781.,. -❑ -w69- 'LDdi33621\ --❑.Manteca'-823-7104- -El'Tracy-83�rB385"' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952011 FEE CK# RECEIVED BY DATE PERMIT`NO. INFO AMOUNT DUE AMOUNT REMITTED ,.-CASH + EH 13-24(REV.101831 �� EH 14-28 SSSS L �