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` APPLICATION FOR PERMIT SAN.JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Appli n is hereby ma a o`he San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is m e comp ia�tivith an Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin cal Health District. J Address 6 City Lot Size PM M Owner's Address y L L 4"-" 11AUbhone 4- " `16`7 � �j Contract dress� �0, icerise No.� �� Phone !�(0 — TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O 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 Dia. of Well Excavation Dia.of Well Casing ! ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t M Public n Other Cl Delta Depth of Grout Seal Type of Grout t I Irrigation Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done, '❑ Type of Pump H.P. State Work Done Well Destruction ElWell Diameter Sealing Material (top 50'1 Depth rMaterial (Below 50'1 ~TYPE OF SEPTIC WORK: NEW INSTALLATION 1 =REPAIR DDITIDN K DESTRUCTION 11 (No septic system permitted if pu tic sew r is available within 200 feet.) Installation,will serve: Rest encs= Commercial— Other ✓ ' Number of living;units: Aumber of rooms f Character of soil:toza deps.oi 3 feet: Water table depth SEPTIC TANK ti ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. R Length of lines Total length/size r r FILTER BED ❑ Distance to nearel st: Well Foundation 0— Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll 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 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,I shall employ persons subject to workman's compensa- tion laws of Ca'fornia." The applicant m s call forVe r ui dpi+nspections. Complete drawing on rave s - �,i jsSigned r� Title: Date: FOR DEPARTMENT USE ONLY / Application Accepted by Date Area [ 2— Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca B23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2DD9, Stk., CA 95201 l FEE AMOUNT DUE AMOUNT EMITTER CK RECEIVER 13Y DATE PERMIT'NO. INFO CASH t EH 1324(REV.1/95) EH 14@e ((!!