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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 0 C T 1 :. 1989 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 Rule",�,gylatio�ns of hNTAL��e�San Joaquin AUH Local Health District. �j t / p�E�RvM�`1IT/SEWCES .Job Address City,r�r-C% � Lot Size PM .•l �'' h one �S �.•�6"a s Owner Address ame _-� J� -- - es �/ Contractor Address a :" ' / License No,'El�}~�, ? Phone ' rS� TYPE OF WELL/PUMP: NEW WELL ❑__/ WELL REPLACEMENT F-1DESTRUCTION ❑ PUMP INSTALLATION ie� 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 El Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing R15—omestic/Private Cl Gravel Pack racy Type of Casing Specifications ("I Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout I Irrigation __ Approx. Depth 1 11 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump -e`K44 — H.P. State Work Don _ Well Destruction i i Well Diameter _ Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is \^ available within 200 feet.) 1 Installation will serve: Residence_ Commercial _ Other 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: _ Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. E-I Method of Disposal / Distance to nearest: Well Foundation Property Line LEACHING LINE (-1 No. & Length of lines Total length/size FILTER BED Ll Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth __ Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS (l rk will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application and that the wo 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date/ OR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO V`/ EH 13-2t(REV.t I n st _ EH 14-26