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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I 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 Ryles and Regulations of the San Joaquin Local Health District. L/ Job Address JO % /Y. ?6.12 1-' City Lot Size PM -�-- Address's NamPhone rQ 67 1 Contracts � rd Address P. `�Ux 1 �� {.C. . -License No.,Qo—W& Phone i?` 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 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 ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta ---Depth-of-Grout Seat _- . __._ 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 - tiller Matefial (Bel`ow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No,septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence-_ Commercial_ Other. Number of living-units:,—L— Number of bedrooms ��.. Character of soil to a depth.of 3 feet: `rr Water table depth SEPTIC TANK ? 'Type/Mfg ` .f Capacityt No. Compartments PKG. TREATMENT PLT. ❑ ice— :S, I- t {✓� � Method of Disposal i /'Distance•to nearest: Well ,F_oundation Property Line LEACHING LINE. -" U? No. & Length of lines Total length/size- FILTER ength/size FILTER BED v '❑ Distance to nearest: Well-- I.Foundation. Property Line SEEPAGE PITS EDR{ Depth I -,[;�-- y Size 'X IL Number 13 SUMPS Distance-to nearest: ti Well Foundation Property Line DISPOSAL PONDS ❑ w ` 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. a ' Home owner or licensed agent's signature certifies the followini: "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." Contractors 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-Cal'rfornia." _-- -- _- -_ The applican must call for req fired inspections. Complete drawing-on.`reverse side. Signed Title: -L e { Date: FOR DEPARTMENT USE ONLY Application Accepted by Date U Area r y Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: le ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"No. + EH 1 -241REV-7/85] , © 1_��7LZ5_ EH 1426