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APPLICATION FOR PERMIT R. SAN JOAQUIN LOCAL HEALTH DISTRICT , 1601 E._ HAZELTON AVE., STOCKTON,,CA _ ��N r Telephone (209) 466-6781 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NVIROME! TAL HEALTH • �� "it�r��' t (Complete in Triplicate) - PERMIT/SERVICES Application is hereby made to the San Joaquin Local Health District forapermit 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. ,:,. ;It Job Address 49, ; City Q Lot Size ,T , PMl Owner's Name _w AddressiZ7 / phone Contractor License No. 3 Phone TYPE OF WELL7.PUMP: V NEW WELL ❑ WELL REPLACEMENT DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ZM`it SEWER LINES DISPOSAL FLD./00 PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS iK INTENDED USE TYPE OF WELL 7 PROBLEM AREA CONSTRUCTION SPECIFICATIONS � .r ❑ Industrial ❑ Open Bottom If Manteca Dia. of Well Excavation Dia. of Well Casing )I Domestic/Private )'Gravel Pack X Tracy Type of Casing Specifications ElPublic O Other C1Delta Depth of Grout Seal Type of Gra t - — i ❑ IrrigationApprox. Depth EJ Eastern Surface Seal Installed by �1% _ Repair Work pone ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Ito Depth /001, Filler Material (Below 50') ll 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 units: Number of bedrooms Character of soil 7dept Water table depth SEPTIC TANKype/Mfg Capacity No. Compartments PKG. TREATMENT Method of Disposal istance to nearest: Well Foundation Property Line � s z i.t 3 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well_ Foundation Property Line DISPOSAL PONDS ❑' w I hereby certify that I have prepared.this application arid 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, f shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shalt employ persons subject to workman's compensa tion laws of Calif rnia." The applicant st call for all required i ctions. Co plate drawing on r arse side.r Signed Title: - Date: FO DEPARTMENT E ONLY Application Accepted by Date Area 071 Grout Pito Inspection by Date � Final In by Data 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 7-1 t FEE AMOUNT DUE AMOUNT REMITTED CK INFO H RECEIVED BY DATE PERMIT No. + EH 1324 IfiEV.1/85) EH 1426 l •�. ////� l/�`7� r�� k ' �S