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F APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT S } 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (200) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ' s 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. t' ` Job Address ✓ / 4!5 jog 1 City ` z Lot'Size - PM I <6 yz It' &6 T - Owner's Name � � ��r�"" Address " Phone Contractor._ ( ddressgd �w1CS6�W� nse No.�S��/3y3 Phone 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 I I TYPE OF WELL PRQBLEMAREACQNSTRUCTION SPECIFICATIQNS� 3 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy4Y. Type of Casing Specifications LJ Public E❑ Other EJ Delta i ,e,JDepth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pumpl H.P. State Work Done ' Well Destruction ❑ Well Diameter Sealing Material [top 501 4 Depth " Filler Wterial_(Below 50') ¢ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is available within 200 feet.} Installation will serve: Residence X Commercial_ Other,_ j v Number of living units: Number of bedrooms W 3f Character of soil to a depth of 3 feet: i Water table depth ° SEPTIC TANK .Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Welt Foundation Property Line LEACHING LINE IL No. & Length of lines Total length/size FILTER BED ❑ Distance t.c nearest: Well Foundation Propeo Line 1 I I # # SEEPAGE PITS El Depth I Size Number SUMPS EJ Distance to nearest: Well Foundation r r Property Line DISPOSAL PONDS ❑ t 4 I f I hereby certify that I have prepared this application and that the work will be done in accordance with SanTJoaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. y R Home owner or licensed agents 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 performance of the work for which this permit is issued,I shall employ persons subiect to workman's compensa- tion laws of California." _ �- _ The applicant ust all for all aired in ctio Complete drawing on reverse sidg. Signed Title:` � — `E" Date: FOR DEPARTMENT USE ONLY Application Accepted by Date -6- - Area Pit or Grout Inspection by Date Final Inspection by �• / Date J t � Additional Comments: ❑ Stk''•466-6781 ❑ Lodi Lk&3621 ❑ Man 823 7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2008, Stk., CA 95201 FE F INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE (,PERMIT''NO. + EH IM1424'IREV28 .1/85) 49 0 r -1-;7EH �y�i/7-