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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 i made in compliance with San Joaquin County Ordjnance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. f Job fA` ressf City Lot Size PM 1 Owner's Nam "=d;de-.sr�L// . f��1L� __._ Phone .t +_ Contractor i Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ T SYSTEM REPAIRT❑ OTHER 0 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 L Gravel Pack ❑ Tracy Type of Casing Specifications F F] Public f7 Other r ❑ Delta Depth of Grout Seal Type of Grout 11 Irrigation —..Approx. Depth I I Eastern Surface Seal'Installed by Repair Work Done ❑ Type of Pump AH.P. State Work Done _ 1 Well Destruction_ ❑ Well Diameter Sealing Material (top 50') Depth "Filler Material lBelow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION LI ; DESTRUCTION Wo septic system permitted if public sewer is 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 '! SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ -_ Method of Disposal Distance to nearest: Well Foundation Property Line _ I d LEACHING LINE ❑ No. & Le gth of Eines' R - Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ! c i SEEPAGE PITS ",X] 'Depth =' € Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line j 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." 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." t Th pfi t st all for al(required ins t' ns. plet"rawing on rev side. { ( t X Signed X Title: Date: r12:7�ez 1 r`FPIR D ARTM NT USE ONLY Application Accepted by _� . a -� Date a' C.� Area Pit or Grout Inspection by Date Final Inspection by �/` l d6�A',� D ote Additional Comments: k ��_ ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ 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 EE INFO AMOUNT DUE AMOUNT REMITTED K U RECEIVED BY DATE PERMIT'NO. + EH 14-24(REV.1/85) 3� _ (,�.�� YO 7 t�7 �3gr5