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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED" (Complete in Triplicate)^ f 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. ' �t did �j� 7 P TIS I. A [`r L o °7° — Job Address _� � � � � �1 11rI/l0 _ City Lot Size� PM' � . �� 4-- V6�3Phone Owner's Name Address --- Contractor -' - f'!f V1A ess - - 4-T License No.q Phone r i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 3` 9 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. !I PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL._.-_� PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ;i Dia. of Well Casing ❑ Domestic/Private El Gravel Pack L1 Tracy Type of Casing '� Specifications T ❑ Public ❑ Other ❑ Delta Depth of Grout Seal a Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done I� Well Destruction ❑ Well Diameter ,Sealing Material {top 50'1 Depth ' Filler Material.(Below 50:) -N TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑' DESTRUCTION ❑ {No septic system permitted if public sewer is j available within 200-feet.] 09 Installation will serve: Residence_ Commercial_ Other ;� 4 < :f 'q !Number of living units: Number of bedrooms" -x � /�� Character of soil to a depth of 3 feet: coc10 Wateril able depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �PKG. TREATMENT,PLT. ❑ ,. . ,`i �+4. �,;, Method of Disposal Z`t Distance to nearest: Well Foundation Property Line 0 LEACHING LINE No. & Length of lines X / G Total length/size v J' FILTER BED ❑ Distance to nearest:! Well Foundation i Property Linle! i SEEPAGE PITS ❑ Depth Sizet Number j SUMPS 171Distance to nearest: Well Foundation y Property Line M f 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, andI ? rules and regulations of the San Joaquin Local Health District. ¢..—,•,. .., .__,� Home owner or licensed agent's signature certifies the following: "I ceititi that in the performance of the work 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: 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 aprh t must call for all quired inspections. Complete drawing on reverse side. Signed Title: Date. � �` S FOR DEPART M USE ONLY N Application Accepted by Date � Area / P Pit or Grout Inspection by Date Final Inspection by A/ Date Additional Comments: r 15 c- !0 vi —f;r- r"— Q { ❑ Stk 466-6781 ❑ Lodi 369-3621 Mante 823-7104 ❑ Tracy 835-$385 ,I Applicant- Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C # RECEIVED BY DATE PERMIT NO. INFO V +EH 1324(REV.1/95) EH 14-26 I