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r 1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 466-6781 , PERMIT EXPIRES 7;,YEAR FROM DATE ISSUED:., t (Complete in Triplicate) i 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. `ta 4 1410 6'7t Job Address �O i � / 3E' 4- City Lot Size '�, PM 00, Owner's Name a Address Phone J / �/ .Cl . �n C 5� a Phone Contractor�Q,�� z, �C Address r6,,26 b License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ i DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ f OTHER ❑ DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 i❑ Gravel Pack ,.„-d "-" ❑ Tracy "`Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _-4pprox: Depth ❑ Eastern Surface Seal Installed by_- Repair Work Done ❑ Type of Pump H.P. `State Work Done Well Destruction , Well Diameter Sealing Material (top 50') Depth f i�. L1&.1 Filler Material (Below 50') Ae a 4hcr if � 4TYRE OF;SEPTiC.WORK:,�NEW INSTALLATION ❑ = REPAIR/ADDITION.❑,. DESTRUCTION El (No septic system permitted if public sewer is - ; available within 200 feet.) .,.. Installation will.serve:—Residence_ Commercial�_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: .I Water table depth SEPTIC TANK ❑ Type/Mfg r Capacity i No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED El Distance to nearest: Well Foundation Property Line i i SEEPAGE PITS ❑ Depth -Size Number i i SUMPS ❑ Distance to nearest: Well Foundation f Property Line r DISPOSAL PONDS 9 ❑ ,I 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"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 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." 'S The applicanttr*st caill for all r. uired 'nspections. Complete drawing on rave side. Signed X f!'-L' s C r l`C� Title: C-, Date: r FOR DEPARTMENT USE ONLY Date 41). b Area Application Accepted by _ Pit or Grout Inspection ►v Date Final Inspection by1 Nr Date")Q=116__F6 i Additional Comments: ` ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca BM-7104 ❑ Tracy� 835-6385` Applicant- Return all copies to: Envir6Amental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F I FEE AMOUNT DUE I AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ; INFO C r + EH 13-24(REV.1 85) {p_13_ EH 14.28