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M 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) a , 4 S 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 M,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 1,7 `7 0 ' ' 71 ,( City Size PM Owner's Name � /[ 114 jAddress Tr6LPhone- - Contractor J` Address Ad License No. t>2 M13 Phone TYPE OF WELL/PUMP: v NEW WELL ❑ 'WELL REPLACEMENT X DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 7Q SEWER LINES DISPOSAL FLO.2fZ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS A i r = INTENDED USE TYPE OF WELL-- PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing X Domestic/Private lit Gravel Pack 1K Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of rout ElIrrigation _Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ T p p Type of Pum H.P. S e or e Well Destruction ❑ Well Diameter Sealing Material [top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Cl DESTRUCTION ❑ (No septic system permitted if public sewer is f - r -available within 200 feet.) Installation will serve: Residence l Commercial— Other S Number of living units: Number of bedrooms04 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance b nearest: Well Foundation Property Line I s LEACHING LINE ❑ No. & Length of lines _ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size f Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 1 ' 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 i 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."Contractors 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." The applic t st call for all requiroq inspections. Complete drawingo eve side. Signed Title: f FOR bEPARTME SE ONLY Application Accepted by Date Pit or Grout Inspection by Date J Final Inspection by Date Additional Comments: A v, ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Cl Tracy 835-63115 wn 7 Applicant-i Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., Cly 9520-4.FEE 4;7 i INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. +6'13-24(REV.1/85Y EH 1428