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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT l 1601 E. HAZELTON AVE., STOCKTON, CA 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.1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �N/ n Job Address��J(nO D� G� a�/'� — City_-S CXR Lot Size_,�/Y PM Owner's Name /O�/''�' `/-nfy`��S Address f� �p Phone Contractor's Name a /t/ ^ License No. L�-�� Phone TYPE OF WELL/PUMP: NEW WELL G WELL REPLACEMENT C DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSALFLD. 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 C Tracy Type of Casing Specifications ❑Public ❑Other ❑Delta Depth of Grout Seal Type of Grout ❑Irrigation ---Approx.Depth ❑Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. __State Work Done Well Destruction ❑ Well Diameter Sealing Material(top 501 Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION C DESTRUCTION 11 (No septic system permitted if public sewer is available within 200 feet.) n 1 Installation will serve: Residence Commercial Other �✓ Number of living units:--k Number of bedrooms A Character of soil to a depth of 3 feet:�YQ"' Water table depth Ile O SEPTIC TANK VO� Type/Mfg Capacity'/b,Of) No.Compartments PKG.TREATMENT PLT.E / Method of Dispo5pl Distance to nearest: Well C Foundation /!7 Property Line -1 LEACHING LINE 44 No.&Length of lines Total length/size UO FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1_ J SEEPAGE PITS Depth SizeS Nurrber r SUMPS ❑ Distance to nearest: Well L4.)_ 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 applicant must or all r red in ctions.Complete drawing on reverse side- Sign ide. Signed x � Title: -- —Date: FOR DEPARTMENT DEPARTMENT USE ONLY Application Accepted by s t A Date Area 7- X Ze _�Date Pit or Grout Inspection by Date -�` Final Inspection by Additional Comments: —_-_-. ❑Stk 466-6781 ❑Lodi 369-3821 ❑Manteca 823.7104 ❑Tracy 83543&ni 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 CK# RECEIVED BY DATE PERMIT NO. INFO CASHEH 13-24 ISEV,10/83) o 7 EH,426