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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. {HAZEL T ON AVE,, STOCKTON, CA Telephone (209) 466-6781 "— PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I , (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. 1, ./ . fel S071- Job Address s f _ City n - Lot Size PM Owner's Name �_ C?- r-�.Ltic1 (Address _, .�s�� ._ Phone Contractor No. �fG Phone21 / TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 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 1'1 Public n Other ❑ Delta Depth of Grout Seal Type of Grout " I i Irrigation _.-Approx. D'ep'th�t'I'Ea-stor`h--Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction .❑. Well Diameter4 Sealing Material (top 50'1 Depth Filler'Material f8elo '} TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION 1 DESTRUCTION I ] {No septic system permitted if public sewer is available within 200 feet.) Installation will server Residence_Commercial_ Other Number of living units: -I-- Number of bedrooms Character of soil to a depth of 3 feet: - _" Water table depth _SEPTIC TANK ❑ Type/Mfg Capacity 0 No. Compartments n PKG. TREATMENT PLT. ❑ V tr Method of Disposal Distance to nearest:' Well Foundation .., Property Line * - E\ LEACHING LIN ❑ No. & Len th of lines 9 Total length/size �9 FILTER BED ❑ Distance to nearest Well Foundation Property Line t� SEEPAGE PITS l 1 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 t rules and regulations of the San Joaquin Local Health District. 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 s 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 mut for requir>sffTn pections. Comp)ae drawing on to rse side. �L � Signed XTitle: _ Date: W-q f FOR DEPARTMENT USE ONLY Application Accepted by �7 i-�fJtLJ�G= Date 2 Area Pit or Grout Inspection by Date Final Inspection by Date �( Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 t Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazeiton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE t AMOUNT REMITTED CK 40 CASH RECEIVED BY DATE PERMIT NO. f -EH 13-24 IREV.1/85) 0 O 60 EH 14-25 7 ^+ 3 Gr