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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 ;:IF ,rr, #_ ti, (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 Regulat nsprtpe San Joaquin Local Health District. ... ,,/1 L rq 7 �.�IL) r O [ ST«lam Job Address City Lot Size PM 0wner's Name Address�� © { f ( hone Contractor's Name � _ f� > rcense No. ' Phone �� TYPE OF WELL/PUMP: NEW WELL . / WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALSYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION .AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF ELL PROBLEM AREA CONSTRUCTION SPECIFI I � S ❑ I strial .710 Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private CAravel Pack ❑ Tracy Type of Casing "' Specifications , Q ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Y TyR of Grout ❑ irrigation —.1lpprox. Dept C� P tern Su ace Seal Installed by—ow Ir Repair Work Done ❑ Type of Pump":&09"a(� N.P.` State Work Done Well Destruction ❑ Well Diameter Sealing Mat rial (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION Q (No septic system permitted if public sewer is J available within 200 feet.) 9 Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms ll Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ff PKG. TREATMENT PLT. ❑ 6 Method of Disposal 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 _ r SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line .DISPOSAL PONDS Cl 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 ma r as to ome subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I cert at in the o e of th work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Ca or The applica tali f 1 re 'r id n i n 'pl dra ng on r ve side. , �de��- 140 Signed Title: Date: FORD ARTMENT USE ONLY Application Accepted by Date 4?_12f__1?_5 Area Pit or Grout Inspection Date Final Inspection by A itional Commen _ 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 2008, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.10/83y l,� �5^1 O� EH 1426 ([[/ 7 y