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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E, HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is heteby 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. r� I Job Address ;? s�S City Lot Size PM Owner's Name : On dips Address a bOp[ 4► t r/l F one g3 'a_3 Contractor r Address .D. License No. 133�b'3 (ihone 2-6 Ss TYPE OF WELL/PUMP: II`I NEW WELL WELL REPLACEMENT ❑ DESTRUCTIO 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 STYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑,Open Bottom ❑ Manteca h Dia. of Well Excavation Dia. of Well Casing x ❑ Domestic/Private ❑:Gravel Pack ❑ Tracy Type of Casing Specifications M Public 1-1 Other H Delta Depth of Grout Seal Type of Grout I i Irrigation -Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done_ p Well Destructions Well Diameter ;ii Sealing Material (top 50'1, ` p Depth_{sir '�� Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I IREPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is x available within 200 feet.) Installation will serve: Residence_ Commercial— Other _ Number of living units: !� Number of bedrooms l Character of soil to a depth of 3 feet: Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ i !n Method of Disposal V I Distance to nearest: Well Foundation Property Line ' LEACHING LINE ❑ No. & Length of lines Total length/size FILTER HED ❑ Distance to nearest: Well Foundation Property Line I. i SEEPAGE PITS I'I Depth Size 1 Number SUMPS ❑ 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 Sian Joaquin Local Health District. Home owner or licensed ageni'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 hiring or sub-contracting signature certifies the following: "I certify at in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of u �1: � EThe applicant II fo r uired inspections. Complete drawing o verse sid Signed X Title: Date: IQ—19-67o DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by _I! Date Final Inspection by Date�-� Additional Comments: I� E ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I. Applicant . Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 .II. INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'No. C H + EH 13-241REV.1/85l E5 � EH 14-2e ��zg� � ii: