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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 465-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED 'g S i`. P 2 11984 SANY-JOAQUIN., LOCAL HEALTH -DISTRICT ,(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. Thfs 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. . 1�1.. 11� . ` City " Lot Size PM ,— Job Address All f� Phone�� Owner's Name Address ag Contractor's Name �� iudr License No. Phone V TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Jr OTHER e 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 fJ Industrial El Bottom ©Manteca Dia. of Well Excavation i T Domestic/ Private L]7 Gravel Pack ❑ Tracy Type of Casin ❑ Public ❑ Other El Delta Depth of Grout Seale�� ❑ Irrigation ___Approxi. Depth —�4Pp ❑ Eastern rfaca Seal Installed by — E`, t j Done Repair Work Done A lStateAkork Type of Pump .�[ Lpe — H Q J _ Sealing Material Ifop 50'1 Well Destruction ElWell Diameter Filler Material {Below 501' Depth Dia. of Well Casing Specifications Type of Grout Vl OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION © DESTRUCTION El (No septic sye withstem permifeettt Installation will serve: Residence _ Commercial — Other y9 G'• Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet:' Capacity No. Compartments SEPTIC TANK ❑ Typd/Mfg -4 Method of Disposal PKG. TREATMENT PLT. ❑ T Distance to nearest:"Foundation Property Line: ` L A,, � �, 1.. _. y, LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to nearest:. i 7 -- -r7 t Total length/size— fell Foundation Property Line if public sewer is U.I SEEPAGE PITS ❑ Depth ^Size...t _ =—Number SUMPS ❑ -Distance to nearest: Well Foundation _ PropeL. rty Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the .work will be done in accordance with San Joaquin Gouty 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 hiringons or sub-contractinsubject t workman'sgompensa- pature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ pe tion laws of California." The applicant ust Cali f I required inspections. Complete drawing on reverse side. Signed K a'� 1 `_ 1 Title: —�. �" ' Date: Date Application Accepted by - / 7 Q pit or Grout Inspection by Date Final Inspection by Date i :Additional Comments: [I Stk 466.6781 ❑ Lodi 369-3621 ❑Manteca 8237104 ❑Tracy 83x6385 i 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 DASH RECEIVED BY DATE PERMIT"NO. EC INFO _ + EH 1344 (REV. 10!931 .Y. y Li 5 EH 14-26