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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELiON AVE., STOCKTON, CA �0py Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �. (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 Regulations of the San Joaquin/ Local Health District. 61l-17 v Job Address , y �1 City Lot Size d PM Owner's Name f'fG" � r Address:.? Phone al Contractor �' Address �UC7Y 147 __ License No. Phone TYPE OF WELL/PUMP: ; NEW WELL ❑ WELL REPLACEMENT-❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 'DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ;r a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑,Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑,F ravel Pack ❑ Tracy Type of Casing Specifications i'i Public 1�'Other Cl Delta Depth of Grout+Seal Type of Grout _ I I Irrigation !--Approx. Depth l I Eastern Surfacenstalled b'y,16 Repair Work Done ❑ Type of Pump H.P. "+ S"tafe.Work bone 'Well Destruction ❑ Well Diameter Sealing Material Itop 50.1 Depth Filler Material-(Be[ 501.1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION.111,'DESTRUCTION l 1 (No septic system permitted if public sewer is O ' / available within 200 feet.) t A Installation will serve: Residence_ Commercial_. Other �[ Number of living units: `14 Number of bedrooms _ Character of soil to a depthiof'3 feet: Walt-CA.Y r,.(4'r ...-..: . _ Water table depth SEPTIC TANK LSI i Type/Mfg G4 nG(_64 Ti Capacity No. Compartments S PKG. TREATMENT PLT. ❑ Method of Disposal: Distance to nearest: Well -� Foundation Jt r Property Line 4— LEACHING LEACHING LINE V--�No. & Length of lines _ w �Q Total length/size FILTER BED ❑ jlDistance to nearest: Well__10Q Foundation _Q,f Property Line SEEPAGE PITS l 1 klDe.pth Size Number „i SUMPS 0 y 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 Di§trict. 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 ri 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." i� The applicant must tali for all required inspections. Complete drawing on reverse side. I t Signed X � > Title: i,Jd f(/1./ Date: ! 3" 1 C FOR DEPARTMENT USE ONLY J j Application Accepted by l� Date /6�� Area it i� �• � n Pit or Grout Inspection by 3 Date Final Inspection by , -iy �A Dat�i_ � Additional Comments:" ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-fi385 Applicant- Return all copies io: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i INFp AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y, DATE PERMIT"NO. ;l +.fH 14-281REV.1/85)