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} C APPLICATION FOR PERMIT I 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 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. .1f� i Job Address r C'��,0'• `V City s`�`u 'Lot Size- A 74c PM i � �! Q L} wner's Name / �CJ1 fi l^��C�9$ Address �0(V A Phone Contractor - Address_S_: l�•� License No. 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 Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �Q ❑ Domestic/Private ❑ Gravel Pack- ❑ Tracy"' Type of Casing a Specifications F] Public ❑ Other M Delta Depth of Grout Seal Type of Grout I t laic ation _ A i' J ._ pprox: Depth i I Eastern Surface Seal Installe-dby Repair Work Done ❑ Type of Pump H,P. State Work Done Welt Destruction ❑ Well Diameter Sealing Material Itop 50'I Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIRIADDITION 1 ] DESTRUCTION (No septic system permitted if public sewer is J vailable within 200 feet.) Installation will serve: Residence f Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth j SEPTIC TANK T } ypelMf9 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 FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS I ) Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line F I DISPOSAL PONDS ❑ I hereby certify that k 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 Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not t 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required nspectio Complete drawing on reverse side. 9 tSigned Title: Date: / FOR DEPARTMENT USE ONLY Application Accepted b Date C, 1�zo—a rea Pit or Grout Inspection y Date Final Inspection by a�I/ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 a teca 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 FEE INFO AMOUNT DUE AMOUNT REMITTED C SH . RECEIVED BY DATE PERMIT'NO. EH 14-26 + EH 13-24(REV,t/95) r - F