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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complete in Triplicate) 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 Jnaquin County Ordinance No.549 for sewage or No. 1862 for well pump and the Rules and Regulations of the San Joaquin Local Health r-: .••at. �� Job Address � ._�ta!_''� �V��. City Lot Size y��` PM f Owner's Name �1F�y1Vq 1A 1 �+ Address r) Phone Contractor's Name eINIA ] SeFIACLicense No. �"t"�� .' Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 x Type`of Casing Specifications 1 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern l Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material ftop 501 , Depth ` FillerWaterial (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION0 REPAIR/'ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is a. available within 200 feet.) i / Installation will serve: Residence Commercial_ i Other Number of living units: 14*1 Number of bedrooms Character of soil to a depth of 3 feet: IS,IAN1QN w y Water table depth SEPTIC TANK V—Type/Mfg C[91 gngn ..�— ==Q1Gli�f Capacity 1"3sQQ No. Compartments CIO PKG. TREATMENT PLT. ❑ 41Method of Disposal , Distance to nearest: Well 0 Foundation Property Line �R LEACHING LINE No. & Length of lines �' d+ Total length/size 14107 FILTER BED ❑ Distance to nearest: Well` Fo ndation lU r Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ A 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 ifornia." The applic t m for all ;qupred Complete drawing an reverse side. Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date / / Area N✓ Pit or Grout Inspection by Date Final Inspection byDate / 7 7-4 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 623-7104 ❑ Tracy 835-6385 - Applicant- Return all copies to: Environments ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE F AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. INFO + EHt3-24(REV.10/83] 1- - ' EH 1 �{ /q/ Tk 4 _ J'