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APPLICATION FOR PERMIT ! 7 3i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA AUG 0 1984 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . SAN JOAQUIN LOCAL (Complete in Triplicate) HEALTH DISTRICT 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. Job Job Address& �T Z�3r: � � ' rf1�V,.V F ��. +• City 4-2,0 _ ,/Ye/ Lot Size PM Owner's!Name P Addres D Pho e Contractor's Name License No, ( (0 D-3 7 36 Phone b TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION � PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ F DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OFINELL �PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by' � Repair Work Done El Type of Pump � H.P. State Work Done Ls Well Destruction Well Diameter Sealing Material (top 60') { Depth Filler Material (Below 501 X TYPE OF SEPTIC WORK:-NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is available within 200 feet.) 1� 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/Mfg . Capacity —No. Compartments _ 1 PKG. TREATMENT PLT. ❑ Method of Disposal. i 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 u SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, sf&fe"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,-I shall employ persons subject to workman's compensa- tion laws of California." The applicant st call for all eq red inspections. Co plate drawing reverse side. qq�// s Signed X _ +title:�, Date: FOR DEPARTMENT USE ONLY t t Application Accepted by Date Area ; Pit or Grout Inspection by Date Final Inspection by Dat 3 Additional Comments: ❑Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104' ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permlt/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. + EH 20IREV.,0/83F W / f