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. I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL 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. p /. ' Job Address zIX 33 L �/OV /c2 City Lot PM Owner's Name/rte Address /z 337 ! Phone 727 J f IV v Contract Address t 0 • 7(P License No.�o__2Z Co Phone 36 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' -1,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 Cl Delta Depth of Grout Seale Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by-" Repair Work Hone ❑ Type of Pump H.P. % •'State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial ° --^`Other .- Number of living units: Number of b room`s Character of soil to a depth of 3 feet: —Water table depth /0 r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT_F T,.. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line F I LEACHING LINE 2/ No. & Length of lines o Total length/size X G� FILTER BED ❑ Distance to nearest: Well Foundationld r Property Line S SEEPAGE PITS 9Depth Size �.� Number _ SUMPS ❑ Distance to nearest: well WO ! 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 following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." r1_ The applicant m call forPequir,,.- ed inspections. Complete drawing an reverse e. f Signed. �. . .Title: - _Date: FOR DEPARTMENT USE ONLY Application Accepted by 'Date Area Pit-or Grout Inspection by - Date4z)lFinal Inspection by Date Additional Comments: ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BYDATE fPERMIT'NO. INFO CASH + EH13-24 fREV.F/85) tl �Y-S EH W26 ,.�