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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) t l 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 Job Address c3, ita lAm-o fs1 i City_&Wm Lot Size PM 1 Owner's Name 03�11IRL.AS Address SM Phone Contractor Address � License No. Phone_ TYPE OF WELL/PUMP: �� .,- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP.INSTALLATION ❑ t SYSTEM REPAIR ❑ OTHER ❑ .r f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public r ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth 1.1 Eastern Surface Seal Installed by Repair Work Done O Type of Pump H.P. State Work Done_ Well Destruction Well Diameter SeaEing Material Itop 50'i w!4,_Cquceay, Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I ) DESTRUCTION l I INo septic system permitted if public sewer is I available within 200 feet.h Installation will serve: Residence_ Commercial____ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: +- Water table depth : SEPTIC TANK ❑ Type/Mfg 1 Capacity No. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal Distance to nearest: Wel Foundation Property Line t LEACHING LINE ❑ No. & LeAg'th of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line I t SEEPAGE PITS l I Depth Size 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 San Joaquin Local Health Di§trict. 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 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 l 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 m t call for all required inspections. Complete drawing on reverse side. Signed X Title: Hate: FOR DEPARTMENT USE ONLY 99 Application Accepted by Date 02-� Area Pit or Grout Inspection by Date Final Inspection by Date o�1` Additional Comments: I ❑ 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 / r FEE INFO AMDUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. o +.EH 13.241REV.t/85Y �� -S7.35- ;eb!>7t