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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT r 1601 E. HAZE.T ON AVE., STOCKTON, CA RECEIVED i Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 0 PT 19 1999' iN COUINTYU - (Complete in Triplicate) SAN JOA Q �,_.., ,3•.,i;. PUBLIC HEALTH'SER ICCs Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the w �11r1F�8'I� 4141k� l �al3 [iLtEd� made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ru es and Regulations of the San Joaquin Local Health Districts. ZT / Job Address �! City Lot Size PM Owner's Name&& Address Phone i Contractor # Address / _ License No&i,24-e Phone TYPE OF WELL/PUMP: iVEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 5�-o SYSTEM REPAIR ❑ OTHER ❑ '.__ .. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 'FOUNR�7ION=-'7AdRICUL`TURE WELLT_ 47"OTHER-W E&—t ' _�'PITS/SUMPS`= INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ In rial ❑ Open Bottom �❑��Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack LJ'Tracy Type of Casing Specifications 171 Public (=1 Other. n Delta Depth of Grout Seal Type of Grout _ I I Irrigation __ _Approx. Deptv l I Eastern /Suy�ace Seal Installed by Repair Work Done L1 Type of Pump A eefe' H.P. I /..� State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth I Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is � available within 200 feet.) Installation will serve: Residence I Commercial_ Other Number of living units: Number of bedrooms 710 Character of soil to a depth of 3 fear Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance',to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size il FILTER BED ❑ Distance'to nearest:' Well Foundation Property Line I SEEPAGE PITS I ) Depth Size Number SUMPS '"'❑ Di�tance'to nearest: Well a"" - Foundation Property Line r. 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. 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."Contractors 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." II The applicant must call for I required in ti s. Complete drawing on reverse side. /f _ Signed Title: Date. �� OR DEPARTMENT USE ONLY Application Accepted by Date/' Area �1 Pit or Grout Inspection by Date Final Inspection by Date �0 Additional Comments: j ❑ Stk 466-6781 ❑ Lodi 369-3&21 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Enviro nmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEI INFO AMOUNT DUE l AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + E14-29IAEt/.liH H 51 { LJ 5. �r��? IV Uh✓�/(J a�JY