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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 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. LJVJ Job Address m5a/ 4 /« City Lot Size PM Owner's Name traj Address Phone t Contractor's Name � �7•�J �(/� GLicense No. '&,r Phone i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION A/ ,{A« `STEM REPAIR ❑ OTHER ❑ I 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 fl Tracy d Type of Casing- Specifications ❑ Public ❑ Other4 ❑ Delta t Depth of Grout Sisal� Type/,of Grout ❑ Irrigation pprox.'Depth 7) Eastern Sr ace Seal lnstalied by Repair Work Done -❑ Type of Pump Lkl H.P, - _ State Work Done 9seweris Weil Destruction ❑ Well Diameter 'Sealing Material (top 50') 7`/��Depth Filler Material (Below 50')r`-� /V�l.(� /�� 5•U�TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if pub 1 available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/MfgCapacity z __�T No. Compartments PKG. TREATMENT PLT. ❑ -•" Method of Disposal I Distance to nearest:" Well - Foundatiori ' Property Line f LEACHING LINE ❑ No. & Length of lines ) Total length/size FILTER BED ❑ Distance to nearest: Well ij Foundation Property Line SEEPAGE PITS ❑ Depth Size r Number SUMPS ❑ Distance to i nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 District. 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 fallowing: "I certify that in the performance of thework for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant fa 11 r pections. Complete drawing on`��rs/ e. SignedMZTitle: Date: =Z��44 DEPARTMENT USE ONLY aa (53 - Application Accepted by ),,,.��FPIR Date 1�'U7 Area Pit or Grout Inspection b Date Final Inspection by 6( G Date a�l I 1 Comments: --- a--- --. --.. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 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 FEECK w INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 6Y DATE PERMIT'NO." +E1 13-241REV.10/83) _ ✓� _ _ 4 i "'-EH 14-26