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y 45 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT N O �Lt�C�a�. 1601 E. HAZEL T ON AVE., STOCKTON, CA k r Telephone QW) 466-6781 n117 � PERMIT EXPIRES 1 YEAR FROM DATE ISSUED b. r•:. _ (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 j 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 iLocal Health District. I � , Job Address City Lot Size L PM s Owner's Name Address r`+ '" r ..�� -•- .. ��.k ,,:h� .�:..� " � �.�.�jt� Phone Contractor Address - 9_ icense.No _—Phone TYPE OF WELL/PUMP:] NE WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP TALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES DISPOSAL FLD. PROP. LINE i 1 FOUNDATION CULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Man Dia. of Well tion Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications - ❑ Public LJOther ❑ Delta Depth of Grout Seal Type of Grout li \ ❑ Irrigation pprox. Depth ❑ Easterh•! Surface Seatl Installed by Repair Work Done Type of Pump H.P. ! State Work Done ' Well Destruc ' ❑ Well Diameter E Sealing Material (top 501 Depth._ # 3 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r available within 200 feet.) , Installation will serve: Residehcet Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: i r Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT:❑ Method of Disposal f L s Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines " '" r` Total length/size FILTER BED 1❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1❑ Depth 1 Size Number k SUMPS ❑ Distance to nearest: Well Foundation -'Property-Line 1 DISPOSAL PONDS 1❑ 1 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. r J i 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: 1,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."1 i The applicant m call for allrequir spections. Complete drawing on reverse side, ) i Signed t Title: ! 7�C/ bat4—e e: FqR DEPARTMENT USE ONLY i a Date `� Area Application Accepted by. Pit or Grout Inspection bye _�- /..Daae - •- - Final Inspection by Date--�7 # .Additional Comments: LJ Stk 466-6781 ❑ L 1 369-3611 ❑ Manteca 823-7104 ❑ Tracy W&6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2609, Stk., CA 55201FEE ; Ifi[) INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMiT•NO. + EH114283-25(REv. EH s/85) - r-,(-7