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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.', STOCKTON, CA MAY 21 1984 Telephone (209) 466-6781 , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' SAN JnAOUIN LOCA. (Complete in Triplicate) HEALTH DISTRICT 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 District. Job AddressCity lV Lot Size PM Owner's Name d Address MZ Phone Contractor`s Name ` a4LLicense No. `l�C I /` 1 Phone TYPE-OF WELL/PUMP.._> ZJ NEW WELL ❑ -WELL-REPLACEMENT ETI-W _-._.J0r6E9TRUCTlON..❑ PUMP INSTALLATION ❑ :;,,� SYSTEM-REPAIR-,K .G OTHER;❑ + dfSTANCE TO NEAREST: SEPTiC=TANK SEWER LINES DISPOSAL FLb." PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 1:1 Manteca Dia. of Well Excavation Dia. of Well Casing ` Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 10 10 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation �Approx. Depth ElEastern Surface Seal Installed by Repair Work Done X Type of Pump H.P. r� State Work Done rn Well Destruction ❑ Well Diameter Sealing Material (top 50') f 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 d� Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth t§ ^ SEPTIC TANK ❑ Tyle/Mfg Ca + pacify n r No. Compartments PKG. TREATMENT PLT. ❑ Method-of-Disposal Distance to nearest: Well Foundation .. Property Line f LEACHING LINE OlNa.'.& Lengthkof-lines .0 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line , SEEPAGE PITS ❑ Depth Size Number �f SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ - -� — � _ ,. v -_ _ __ _ i:i 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."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." _3r The applicant u t call f all requir spe t' s. Complete drawing on fe a side." Signed Title Date: �I FOR DEP TME" USE ONLY Application Accepted by Date i 4�f� Area Pit or Grout Inspection by Date Final Inspection by C/ Date Additional Comments: ry ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 �^ Applicant- Return all copies to: Environmental Health Permit/Services 1601 S. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE 6 INFO AMOUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE PERMIT'NO. �! + EH 13-241REV.10183] 28 EH 11 -- - - 1 -