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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) iD 1— —7 3 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 Address `" City Lot Size Z M Owner's Name Address J v _, P Phone r Contractor's Name` i se No. Phone 5�yS -S� 2 TYPE OF WELL/PUMP: EW 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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Weil Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Zy ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 O 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: 'A Number of bedrooms L. Character of soil to a depth of 3 feet: Water table depth 04 SEPTIC TANK ❑ Type/Mfg alfL Capacity No. Compartments Z PKG. TREATMENT PLT. ❑ Method of Dispos io Distance to nearest: Well Foundation Property Line LEACHING LINE It—No. & Length of lines Total ength/size FILTER BED ElDistance to nearest: Well Foundation Property Line SEEPAGE PITS Depth2i, 2 .2 N ber SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Sart 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."Contractors 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 ust call for all required in ctions. Complete drawing on reverse side. Signed Title: _� Date: `4� ~C�G T FOR DEPRTMENT USE ONLY / Application Accepted by Date "'? Area or Grout Inspection by 17e / at Final Inspection by vAd 'tional Comments: fJ' Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Apphc nt- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CAK RECEIVED BY DATE PERMIT''NO. + EH1324(REV.10/83) f///Jry r� ;..$�_ )� EH 14-26 "' " 4�-"�