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APPLICATION FOR PERMIT }y�� 0 SAN JOAQUIN LOCAL HEALTH DISTRICT Ike t}L S {-Gt 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 o L ` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the Sar Joaquin Local Health District for a permit to construct and/or install the work herein described.TNs 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 /��'%® C� Cit of Size PI41 Owner's Nam / Oyz- Address Phone b' Contractor re'sIn nse No Phon� TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 68 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS `V ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout Ilm I I Irrigation —Approx. Depth I I Eastern- Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done t.1 Well Destruction ❑ Well Diameter eating Material Itop 50') Depth Filler erial (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ( REPAIR DDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) .� Installation will serve: Residence_ Commercial Other - Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg —y CapaciVA9 d v No. Compartments PKG. TREATMENT PLT. ❑ [ h Method of Di Nasal Distance to nearest: Well D Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size �. FILTER BED IXDistance to nearest: Wall Foundation_7 Q 12 Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ 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 manner as to become subject to workman's compensation laws of California." Contractor's 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 applicantu CalLEpr a fired inspect' S. mplete drawing on reverse side. Signed % /J`y`R , Title: Data: FOR DEPARTMENT USE ONLY Application Accepted h �"r tie. H4 n� �- f3-85 P V rj 4t Date � Area Q Pit or Grout Inspection by Date Final Inspection by�\ / a .tet 4 Date / Additional Comments: 0 r.� 4_� ❑ Stk 466-6781 ❑ Lodi 369-3621V ❑ Manteca 823-7104 ❑ Tracy 83 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 tv INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY f ,, DATE PERMIT'NO. +.EH I}N(REV.irxsl -70 / "' f3� _, ,2 J/ ` EH 14]8 LJ J 7