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APPLICATION FOR'PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROW 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. ` 'A�n� t- �, y Job Address -3 ��_� �! � '' v4 /��'t� City Lot Size PM Owner's Name � Address 5141' Phone 7 ?"3 7e n 'Contractor's'Nains t' �`� "l:icense No. �p p —" -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 I PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS-- El Industria{ ❑ Open Bottom ❑ Manteca l Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private M Gravel Pack C1Tracy it Type of Casing _' , Specifications I ❑ Public ❑ Other ❑ Delta I Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern j Surface Seal Installed by r i Repair Work Done ❑ Type of Pump H.P. X State Work Done rx Well Destruction ❑ Well Diameter Sealing Material Itop 54'1 Depth -1Filler Material (Below 50'1r TYPE OF SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITION ❑' DESTRUCTION No septic(system permitted if public sewer isl �' available within 200 feet.) S Installation will serve: Residence 4— Commercial_ Other i Number of living units: J— Numbbr of b9dro ms , .I Character of soil to a depth of 3 feet: fk a 7 Ismt Water table depth I SEPTIC TANK 9P___Type/Mfg ' Capacity No. Compartments PKG. TREATMENT PLT. ❑ / Method of Disposal `� I ��4 (Foundation f Property Line � � rt i Distance to nearest: Well, t i LEACHING LINE moo. & Length of lies -Total length/size i FILTER BED ❑ Distance to neardst: Well f!". `Foundation -Ue Property Line / n 1 SEEPAGE PITS Depth Size — +Number. 4i 1 SUMPS ❑ Distance to nearest:, t, Well .,Foundation Property Line l44 DISPOSAL PONDS 13 I hereby certify that I have prepared this application and that, a work will be done in accordance with San.Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. t Home owner or licensed agent's signature certifies the following: f"fI 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 workrr an'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 whit�this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California' The applicant must r Ire -i ons-Complete-drawing ori'reverse side. Signed Title: Date: 4 �� 1<FOR DEPARTMENT USE ONLY }� �j Application Accepted by 1 r :� Date � f "'� Area -la-�s . y- ) -Ys Pit or Grout Inspection by Date Final Inspection by Date 1 c12 Additional Comments: ❑ Stk 466-6781 Cl Lodi 369-3621 ❑ Manteca 823-7104 Traoy 1835 girt • ;gyp Applicant- Return all copies to: Erivironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,4CA 95201 4_ 1 �A FEE INFO AMOUNT DUE AMOUNT REMITTED _CC4KSH_ _ RECEIVED BY DATE PERMIT'NO. +EH 13-24(REV.10/83) `�� r EH 14Im