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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT S 1601 E. HAZE,—ION AVE., STOCKTON, CA s ]. Telephone (209) 466-6781 I 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.; - I I � - City Lot Size PM , I .. _ 2`W)Job Address �7 p �l n jC�'� fPhone 4 S to 70 Owner's Name W Address r!, - License No, 2—� � Phone 6 b1 G)L� Contractor r Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION, ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i. INTENDED USE TYPE OF WELL PROBLEMAkREA CONSTRUCTION SPECIFICATIONS i Dia. of Well Excavation i Dia. of Well Casing ❑ Industrial El Open Bottom LI Manteca` Specifications F ❑ Domestic!Private ❑ Gravel Pack ❑ Tracy Type of Casing— M Public _n Other Cl Delta Depth of Grout Seal Type of Grout Ligation -Approx. De�p3�' 1 1 Eastern Surface Seal Installed by ' 1,r✓cn�r, H.P. a State Work Done Repair Work Done e Type-of°Pomp k Well Destruction ❑ Well Diameters Sealing Material [top 50'1 Depth 1 �` Filler Material (Below 501 TYPE.OF SEPTIC WORK: NEW INSTAClAT10N; 1 REPAIR4ADDITION l 1 DESTRUCTION [ I (No septic system permitted if public sewer is available'within 200 feet.) Installation will serve: Residence_ commercial_ Other t ! [ t . ! Number of living units: Number of bedrooms � I �l �I � 'p F. I Character of soil to a depth of 3 feet: '�" "' _ W ter i�bl AWN ll SEPTIC TANK ❑ Type/Mfg .Capacity No'. Compartments j I Method of Dispose! PKG. TREATMENT PLT. � 11 pp � Distance to nearest: Well r Foundation Property Line rr 0198 l< f r LEACHING LINE Gl No. &'Length of lines f� Total length/size FILTER BED ❑ Distance to nearest: Well +"' Foundation PropertyF SEEPAGE PITS 11 Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t `f I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stat11aws, and ( rules and regulations of the San Joaquin Local Health Di1trict. 1 rtify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: "I ce empioy any person in such manner es to become subject to workman's compensation laws of California." Contractors 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 ust call for all required inspections. Complete drawing on reverse side. Signed X t e: ) _ Date: �/7DEPARTMENT USE'ONLY I Date Area pee Application Accepted by If Pit or Grout Inspection by ate Final Inspection by Date Z ` fAdditional Comments: f ❑ 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 AMOUNT DUE AMOUNT REMITTEDftCK RECEIVED BY DATE PERMIT'NO.FEE INFO r 1 + EH 13-241REV.1/85) -Z I EH 14-29