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APPLICATION. FOR. PERMIT r SAN .lOAQUIN L®CAL HEALTH DISTRICT 1984 1601 E. HAZEL T ON AVE., STOCKTON, CA 21. Telephone (209). 466-6781 't Cal rs M5'�t f' ^1 _,,1 Y,n -1 }�*r�. �� .;-r L . ,.y LOCAL PERMIT EXPIRES 1.YEAR�FROM DATE ISSUED ,toat,R�4s � i'i' b v 9 �a'rt{b1il iii .a.: V'.. *i'(Complete.fin Triplicate): - .. 't ; `. 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 Distri♦ct.-ft.7?mniE1ttll-.4.,r�r~uoj eics ' _ ,;;t 0 yDS *,rj it .v If, v:! i .,i; E.,;, e,4,4—/.d(Ca+ J�//1/JCOI `tt3it� Oil x 'Citv/'Vfd.-__2 .Lot Size ' i; PM Owner's Name - Address / �,—`1 QPhone V Contiactor's Name '_ License No. Phone a CAP TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR j OTHERS 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 ❑ 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.L S W k one Well`Destruction ❑ Well Diameter Sealing Material (top 50`1' Depth Filler Material (Below 501 l 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 t Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:.' ): r Water table depth SEPTIC TANK El/M Typefg -M-�ti. t, b. Capacity No. Compartments d" PKG.'TREATMENT PLT.' ❑ � `�M` r r Method of Disposal Distance to nearest: Well' 1 Fyyou6clation Property Line LEACHING LINE } ❑ ;No. & Length of lines ' -- Total length/size FILTER BED "" ❑ 'Distance to nearest: y Well" 4 - "Foundation Property Line SEEPAGE PITS ❑ Depth Size I NurrQ 'SUMPS` 7 ❑ Distance to neal`est:Weil' t '"a" Foundation } Property Line DISPOSAL PONDS. Ell i l 1 i 1t�0 r �f9 6 U 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 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." ... q - . - F k 'The applicant must call for all required inspections. Complete drawing :on reverse side. i' i Signed X�-t-�� Title: Date: t. FOR DEPARTMENT .USE ONLY tea, -;tib. Application Accepted by Daae 2- Area i 2 7 V1 41 - .Pit or Grout Inspection by ! I Date Final Inspection by Date' l" -Additional Comments: t i:i ❑ Stk 466-6781' -❑ Lodi 369-3621 '' ❑ 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 i + EH 13-241REV~10/83) EH 14-26 " FEE INFO' AMOUNT OUE 1' , AMOUNT REMITTED"RECEIVED BY CASH ` DATE PERMW-N0, NIS -�S i -13'3S. 0 ` � �`i --I�