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3 APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA I 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."�. _4 Job Address �Pl aAr City Lot SizeL% PM Owner's Name VL CL 'Address y �r Phone Contract .� r �c of 4" Address" License Na '21 Phone �+ TYPE OF WELL/PUMP: °� NEW'WELL E] WELL REPLACEMENT ❑ DESTRUCTION ❑ F ;p�UMP INSTALLATION ElSYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKS = SEWER LINES —.DISPOSAL FLD. PROP, LINE =j 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 ti INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 3 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Ria. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 'f Specifications ❑ Public ; ❑ Other I ❑ Delta Depth of Grout Seal ` Type of Grout D Irrigation .—Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. y -State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 ! Depth s. filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ PAI /ADDITION �DESTRUCTION ❑ (No-septic system permitted if public sewer is I f I available within 200 feet.) Installation will serve: Residence Commercial_ Other k Number of living units: it Number o droo s _3 Character of soil to a depth of 3 feet: z 'ti___;;_.__-. - -='`"` "" Water table depth AS SEPTIC TANK ❑ Type/Mfg Capacity _ �. No. Compartments PKG. TREATMENT PLT. ❑ Meth_od of Disposal �•` Distance to nearest: Well Foundation Property Line t LEACHING LINE 64-*"No. & Length of lines f— O f1l !Total length/size �r r FILTER.BED r ❑ Distance to nearest: Well_, Foundation��....=.� Property,l $ _ Line w SEEPAGE PITS 2'0'Depth Size Number k SUMPS' ❑ Distance to nearest: Well `/SIC/— Foundation Property Line -- DISPOSAL PONDS Cl - v 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 fdr wFiidh this permit is issued, I shall not empldy 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." r The applicant st call for al required inspections. Complete drawing on reverse e. i Signed 12 Title: '•Date: & 4 -97 FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Z Final Inspection by pate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823.7104 ❑ Tracy 8354M5 4 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F I FEE CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 14-261FEV.t/951