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APPLICATIO14 FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE' ON AVE., STOCKTON, CA Telephone (209) 466-6781 1 PERMIT EXPIRES 1 YEAR 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. I Job Address U f /�01 �/ eRwczt� CitY Sy O �� r� of Size PM ( Owner's Nam • !f J Address � .�.� �.. Phone �� 7¢ Conlracto ��/�g� d � _Address [� r License No. 0 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 FOEINDATION 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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications P Public n Other 71 Delta Depth of Grout Seal Type of Grout _ I I Irrigation --Approxi Depth l I Eastern Surface Seal Installed by 1 Repair Work Done )!F- Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 -Depth Filler Material (Below 50') `l' TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I ) DESTRUCTION I I'INo septic system permitted if public sewer is A/' t available within 200 feet.) Installation will serve: Residence C mmercW Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:# " ' Water table depth � SEPTIC TANK ❑ Type/Mfg' Y Capacity Na. Compartments':_ PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation P-0 Property Line LEACHING LINE ❑ No. & Length of;lines "-` Tota! length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS41 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ } - ' � t I hereby certify that I have prepared this application and that thewwill be done'in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin'Local Health District. 1 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." The applicant mu or all required inspec ' C latewing on r 7Me side. i Signed X w- Title: Date: L ��9 FOR DEPARTMENT USE ONLY Application Accepted by Date Area [J Pit or Grout Inspection by } Date Final Inspection by Date J_-'?-97 Additional Comments: 1 lk ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca - 823-7104 . '❑ Tracy .,835:62i85 Y. Applicant- Return all copies i6 Environmental Health Permit/Services 1601 E:Hazelton*Ave.,-P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUECK INFO AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +.EN 13-24{qEV.1/85) � '�