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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 VYEAR 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 Rgles and Regulations of the San Joaquin Local Health District, Job Address Zd S'/5`/f' � City Lot Size PM - Owner's Name ��« P Address Add - - - - . --� � Phone - - — Contractor r, +'—" �4'C Address License No. o6d 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 EF Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private t ❑ Gravel Pack ❑ Tracy -" Type of Casing .Specifications ❑ Public ❑ Other3 ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _--Approx. Depth C1 Eastern Surface Seal Installed by ` rS I Repair Work Done ❑ .Type of Pump H.P. State Work Dona Well Destruction ❑ Well Diameter Sealing Material (top 50') ' Depth Filler Material (Below ) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIO DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) I Installation will serve: Residence_ Commercial_ Other f Number of living units: Number of'bedrooms Character of soil to a depth of 3..-feet: I F j SEPTIC TANK [_1TypelMfg I �''�� # r Wate,.table,depth.- , Capacity No. Compartments PKG. TREATMENT PLT. ❑ ` t Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE �.'&-Length-of-lines—l� ,rF Total length/size FILTER BED ❑ Distance tol,nearest: Well A Foundation Property Line I SEEPAGE PITS JP"—Depth 2 FT Size ,.,Number, _ SUMPS ❑ Distance to nearest: Well _ L._I��Foundat+on�PropertyrLirae . � t 's' DISPOSAL PONDS ❑ 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. f Home owner or licensed agent's signature certifies the following: '9 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." J The applicant must a +one Complete drawing on reverse side. Signed f} Title:' —�3- 4-3- • , Date: y FOR DEPARTMENT USE ONLY Application Accepted by Date � � � r Area Pit or Grout Inspection by m .` Date, Final Inspection by Dat r� Additional Coments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Vt Manteca .823-7104 ❑_Tracy 835-6385 Applicant• Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20f6, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT NO. INFO CASH 1 p A + EH 14-24(REV.1/85Y EH T428 �