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' APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR'FROM-DATE ISSUED (Complete in Triplicate),. "t',.: .. .. a..�i' n..i,• Sr :` .,{`; Ci a 4 i.l^ 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 Health District: sewage,or No. 1862 for well/pump and the,Rtiles and Regulations of the San Joaquin ,.:°�s�rt t.w flea ..ti: ..,„�.-8 ;1r.�.tls.t .::u°.,. .�• Local 4 ib?t -In Zf q&LZZZ !"''nEy ' i City Lot Size PMJob Address -Owner's Name Address Q i Phone 01 AV wa License -No Ko. •' 7 Contractor v °� Address Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ae 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 ,P1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other - ❑ Delta Depth of Grout Seal Type of Grout El Irrigation ---Approx. Depth 11 Eastern Surface Seal Installed by F Repair Work Dane JX Type of Pump A." H.P. State Wor Don Well Destruction ❑ Well Diameter Sealing Material (top 50') ti Depth Filler Material (Below. { TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is I 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 k SEPTIC TANK ❑ Type/Mfg Capacity. No. Compartments PKG. TREATMENT PLT. ❑ a n Method of Disposal Distance toonearest: -Well Foundation Property Line LEACHING LINE ❑' No:'&_Lengt6 of lines Total-length/size FILTER BED ❑ Distance to nearest: Well - Fondation_ 'Au _ Property Line„ r RT w t r+ ! SEEPAGE PITS 13Depth Si e" �`' tl'�` Number --.--SUMPS— ❑-T Distance to nearest: Well Foundati4 on � T �Property:tine_ -=• "--�^ _ -. '�"'-- 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. 3 Home owner or licensed agent's signature certifies the following: "I certify that in the gerfdrmance 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 la±vs 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.— The applicagWnust call for al a fired inspections. Complete drawing'on rav se side. Signed 4jAdtA.� "� - Title: Date: r OR DEPARTMENT USE ONLY r�//-.,i �� ' Application Accepted by Date `� Area Pit or Grout Inspection by Date Final Inspection by Date i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 36.9-3621 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT`NO. - I N FO / Q�/�� + EH 13-24(REV.1/85) ✓ �� C�•7 1� ^�� EH 14-25