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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 (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 Ryles and Regulations_of.the San Joaquin Local Health District. L s�# _ �. Job Address s a~ 0(3 R 12T City r' 'Lot+Size "" PM h 7 Owner's Name A fi K Address �3 - O �j}� -. I -Phone - Contrac— 11tor� PA 12 kia I d—Address O 1'i.J.c.t , an,� W�} License No. Phone B TYPE,OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El- PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE d FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �f k INTENDED USE.....�,»...�TYPE.OF•WELL-,....PROBLEM-AREA -_,.CONSTRUCTION SPECIFIC-ATIONS--,% 01 Ll Industrial 13Open Bottom ❑ Manteca Dia. of Well Excavation # Dia. of Well Casing 11es Domtic/Private ❑ Gravel Pack 17 Tracy Type of Casing i Specifications 13 Public ❑ Other ; LJ Delta Depth of Grout Seal k P � p Type of Grout F ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump E ,pState Work Done Well Destruction LlWell Diameter ea,ling Material (top 50')Depth ller Material (Below 501 E TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIWADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is ! rte.,,.,_.. ., C available within 200 feet.l Installation will serve: Residence 1� Commercial_ Other Number of living units: Number of bedrooms Character of soil 4o a depth of 3 feet: t x Water table depth iSEPTIC TANK Type/Mfg wCSj) Capacity No. Compartments PKG. TREATMENT,PL i- Method of Disposal r Distance' to nearest: Well Foundation • .� Property Line ( LEACHING LINE I ❑ No. & Length of lines Total length/size i FILTER SED ❑ Distance to nearest:p Well Foundation Property Line I SEEPAGE PITS ❑ Depth + r Size Number E SUMPS ❑ Distance to nearest: Well Foundation Property Line a DISPOSAL PONDS Ll ' I hereby certify that I have prepared this application ao f 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 District. Homeowner 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 subtect,to workman's compensation laws of California." Cont'ra tion.laws of California." ctor's hiring or sub-contracting signature certifies the foilowing:`1 certify-that-in•the-performance-of-the-work for wh1ch'thi5 perrnitis issued;1�ail employ persons subject to workman's compensa- The applicant ust II for all�Guired ins tions. Complete drawing on reverse side. Signed d ,-1 11-, `� Q12 Title: Date: FOR DEPARTMENT USE ONLY ' Application Accepted by ' ( Date r "� Area V Pit or Grout Inspection by Date Final Inspection b Dafe-� Additional Comments: ❑ Stk 466-6781 ❑ Lodi &&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- !fr FEE 1 CK 0 INFO AMOUNT DUE r AMOUNT REMITTED CASH RECEIVED BY DATE PERMI7'N0. +EH]324(REV.1/85) EH 1426 �✓ I t Y7-1 71y' /y'