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- i 1 APPLICATION FOR PERMIT �- 1 SAN JOAQUIN LOCAL HEALTH DISTRICT �_� 1601 E. HAZELTON AVE., STOCKTON, CA N`o W C 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. Job Address /4�_az/ 1T Z — �/ CityLot Size 7�� p PM �:+�^ Owner's Name P/4 +�5 /fly Address _/,li all 1�/Q�iS��'L- Phone Contractor Address License No. Phan 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 4 INTENDED USE ,, TYPE OF WELL: PROBLEM AREA ,CONSTRUCTION SPECIFICATIONS _ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation a Dia. of Well Casing i ❑ Domestic/Private .17-1 Gravel Pack C1 Tracy Type of Casing Specifications ('1 Public ' F1 Other C1 Delta Depth of Grout Seal Type of Grout _ 1 1 Irrigation _.Approx. Depth I I 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 50') ~` TYPE OF SEPTIC WORK: NEW.INSTALLATION I I REPAIR/ADDITION [ I DESTRUCTION (No septic system permitted if public sewer is 7 1t & available within 200 feet.) —141x Installation will serve: Residence f Commercial_ Other I . Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK - ❑ Type/Mfg I Capacity--------!— No. Compartments PKG. TREATMENT PLT. ❑ # t Method of Disposal Distance to nearest: Well I Foundation a Property Line ; LEACHING LINE ❑ No. & Length of lines t Total length/size. FILTER BED ❑ Distance to nearest: Well f Foundation = Property Line SEEPAGE PITS 11 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line t A 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 no 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 compensal tion laws of California." _ # t: The applican ust call for all'required inspections'Complete drawing on reverse side. " Signed X Title: � ,71 DEPARTMENT USE ONLY Ut Application Accepted by AA.4111 Date Area Pit or Grout Inspection by ate Un �� Final Inspection by �� Date ��j'5 Additional Comments: '_� © 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 )NFO omC 46 FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY / DATE PERMITNO. + EH13'241REV. EH 1428