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r 4. ., APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 9 YEAR FROM DATE ISSUED (Complete in Triplicate) }t ' Application is hereby made to the San Joaquin local Health District for a permit to construct and/or install'thefwork-'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: } 9- �4 rGt Job Address %* City Lot Size I M Owner's Name Yi- Address Y Phone Contractor � e r _Address 1.0 C1U License No.r�� f Phone 5 .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. ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications -� ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _-Approxi Depth I I Eastern Surface Seal Installed by ! Repair Work Done ❑ Type.of_P-ump------ ___H_pWork Done Well Destruction ❑ Well Diameter Sealing Material {top 501 I Depth filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION l (No septic system permitted if public sewer is i available within5200 feet.) [ Installation will serve: Residence' 'Commercial— Other - v Number of living units:- ! Number.of bedrooms Character of soil to a depth-of 3 feet. Water table depth SEPTIC TANK ❑ T t ype/Mfg- Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method o'f 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 SEEPAGE PITS I I -Depth Sizes Number SUMPS CI .Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f 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 D"!strict. Home owner or licensed agent's signature certifies the following: "I certify that in the performan6e of the work for which this permit is issued, I shall not. employ any person in such manner as to become subjectlo workman's compenstation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "1 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 Calif nia." ' The app)can s call for alllrequired inspections. Complete drawing on reverse side. t I Signed ! Title: r � _2 el— Data:.. D� i 'i FOR DEPARTMENT USE ONLY �C. Application Accepted by I Date if7 7 Area f- -� - Pit or Grout Ins pection by Date - nal I sp coon by��'—''` � Date Additional Comments: , ❑ Stk 466-6781 ❑ Lodi 369-3621 Ll Manteca 823-7104 !NBNTrae i -.835-6385. Applicant Return all copies to: Environmental Health Permit/Services 1601*E..Hazelton Abe., P.O..Bo , Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY { DATE PERMIT NO. 644A;7 + EH 10-24(REV.1/95) ]•.--e �(iA I] Q�_�