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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZEL T ON AVE., STOCKTON, CA REc IVSD Telephone (209) 466-6781 MJUN 1 4 1993 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUiN COUNTY (Complete in Triplicate) PUBLIC HEALTH SERVI��ik Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install theUW�WWTftbq Y� �n made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations o t Local Health District. r Lot Size PM Job Address I City I Address e25 � S '� - Phone F Owner's Name ��// ,�++�/ Contractor Address ��3~ Livens No.ZZ? Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ PUMP INSTALLATION 9. SYSTEM REPAIR ❑ OTHER C-1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTE DED USE r TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ I strial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �,� e of Casing Specifications Domestic/Private ❑ Gravel Pack �IracY Type g . I'l Public ❑ Other C] Delta Depth of Grout Seal Type of Grout I 1 Irrigation '! -Approx. Depth l 1 Eastern Surface Seal Installed by - IJV 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 I] REPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence._ Commercial_ Other Number of living units: Number of bedrooms C/] Character of soil to a depth of 3 feet: Water table depth Capacity No. Compartments SEPTIC TANK L) Type/Mfg PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I . " LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I [� SEEPAGE PITS I.1 .1_ Depth Size Number y SUMPS �,: ' LI L Distance_to nearest: Well Foundation Property Line 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 D,%trict. ify that in the performance of the work for which this permit is issued, I shat)not Home owner or licensed agent's signature certifies the following: "I cert i 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 call for all required inspections. Complete drawing on reverse side. s Signed X Title: Date: ,r!' // FOR DEPARTMENT USE ONLY p Application Accepted by Date �r ` Area 022�&� Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 ,.i FEE A OUNT DUE AMOUNT REMITTED CK ECEIVED BY p TE PERMIT NO. INF +.EH 132A(REV.t i x 51 3 � EH 14-26