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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL TON 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 complid-nce-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. Job Address 1-1 Imem—r, �a 4Z-e_ ,City gy Lot Size PM IF 's Name E1 A44n,0,4 /—,q Phone Owner Address 16 0/ Contractors( Address / 2,2- BAI License No. L'-.-Y_Phian,4;:� TYPE OF WELL/PUMP: NEW WELL D. WELL REPLACEMENT 11 DESTRUCTION 1-1 PUMP INSTALLATION 0 SYSTEM REPAIR L OTHER D 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 L1 Industrial El Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing 0 Domestic/Private" E) Gravel Pack U Tracy Type of Casing Specifications 171 Public Cl Other [7 Delta Depth of Grout Sea] Type of Grout--_ I I irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L1 Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material {top 501 Depth Filler Material Welow 50'1 --TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I DESTRUCTION (No septic system permitted if public sewer is 4 rXavailable within 200 feet.) Installation will serve: Residence Commercial— Other. Number of living units: — Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK E3' Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. El. Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED El Distance to nearest: ' Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS F1 I 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. I Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work fol r 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 applica t must call for all required inspections. Complete drawing on reverse side. Signed X Title- Date: 'FOR DEPARTMENT USE ONLY Application Accepted by CM LEV—, Date Area Pit or Grout Inspection by Date Final Inspection by &-1-4 A- Date Additional Comments: L1 Stk 466-6781 0 Lodi 3\49-3621 0 Manteca 823-7104 0 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 K RECEIVED By DATE PERM17,NO. INFO + EH 13-2 4 IREV,1 9 51 EH U-26