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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 TYEAR 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 her described. This application is I made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weil/pump and the Rules and Regulations of the San Joaquin t Local Health District. "�r�4m Cit1,0t Lot Size 6 , PM t Y Job Address �j Address Phone Owner's Name �y /� License No.- �Phone 2 _`S Contractor �-��L� Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11DESTRUCTION LJ PUMP INSTALLATION ❑ SYSTEM REPAIR 1-3T OTHER 171 DISPOSAL FLD. PROP. LINE — DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESi r' FOUNDATION AGRICULTURE WELL OTHER WELL— INTENDED INTENDED USE _ T.YPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Industrial ' ❑,OpegBottom L] Manteca Dia. of Well Excavation Type of Casing Specifications ❑ Domestic/Private ❑Gravel Pack ❑ Tracy yp 9 Type of Grout f 1 Other" Cl Delta Depth of Grout Seal yp l"] Public f ° 'r-Other—' I I irrigation t _Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of'Pump H,P. State Work Done — Well Destruction ❑ Well Dieter Sealing Material /top 50') Depth Filler Material (Below 50'1 TYPE OF SEPTIC,WORK: NEW INS-T-ALLATION I.l LPAIR ADDITIONt.I DESTRUCTION ! I (No-seaya ilabpti:bi system pe rented if public sewer is R� eet ii` Installation will,serve: es�dence Commerciah_ 0 r Number of living units: ._ Number o1 bedrooms eet Character of.soil to a depth of 3 feet.' Wapth �j SEPTIC TANK`,F* ❑ Type/Mfg T NentsMeposalPKG. TREATMENT PLT. ❑ "'� � e Pro ert pistance to neaest:� Well' Foundation P YLEACHING LINE l No.-&=L-egth of lines A' Czs Total length/size ooll ' fo _. -_— -Line_rte—_— FILTER HED �J. O Distance to nearesti3 r Well ._.—,fesundation_ Propertycy Number SEEPAGE PITS�"- r. . . Depth. Size `"� • I" `Foundation — Property Line SUMPS E1"'DiStance to nearest: Well DISPOSAL PONDS ❑ W i I hereby certify that l have prepared this appliCatiori and'that the work will be done in accordance with San_Jo,aquin county ordinances, state laws, and ' rules and regulations of the San Joaquin,Local Hea16 0lstrict. 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 certifies the following: "I certify that in the perform_ince of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant t call for all q r d inspections. Complete drawing an reverse sid t Signed X Title: Date FQR or USE ONLY �7 Date �f" Area Application Accap by Pit r Grout Inspection by Dut � Final Inspection by Date Additional Comments: - El69 Stk 466-6781 i] Lodi 3 -3621 ❑ Manteca a23-7104 ❑ Tracy 835-fi385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK RECEIVED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CASH F +.EH 13-241REV.1/85) �� fg INFO EH U-25 'Ar