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J APPLICATION FOR PERMIT 4 SAN JOAQUIN LOCAL HEALTH DISTRICT y);4- 1601 E. HAZE'.-TON AVE., STOCKTON, CA TT � Telephone (209) 466-6781 ,p PERMIT EXPIRES 'I YEAR FROM DATE ISSUED V » (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 A made in compliance with San Joaquin County'Ordinande No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. s3 S i T. Job Address 2�0 ' I,�1 u, .�n.c 4 0 City Lot Size PM Owner's Name i�S`� 1 b �✓S Address J U h Phone c' —� Contractor .,� Address License No. 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 d r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION'ION'SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ! Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing i Specifications ❑ Public ❑ Other t Q Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx.' Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. "" State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501- Depth r Filler Material (Below,50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ �DESTRUCTIO INo septic system permitted if public sewer is f•} , �` available within 20(1 feet. Installation will serve: Residence Commercial_ Other, Number of living units: Number of bedrooms F Character of soil to a depth of 3 feet• Water table depth d SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ i - _ . Method of Disposal r Distance to nearest: Well *' ' Foundation ii Property Line F ' LEACHING LINE ❑ No. & Length of lines Y y Total length/size j FILTER BED 0 Distance to nearest: Well Foundation Property Line a SEEPAGE PITS ❑ Depth Size Number 4 SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 f rules and regulations of the San Joaquin Local Health District. 1 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,1 shall employ persons subject to workman's compensa- tion laws of California." t The applican must call for all required inspections. Complete drawing on reverse side. Signed Title: Datl-, � � ( FOR DEPARTMENT USE ONLY �rf� Application Accepted by Date y Area Pit or Grout Inspectio ! Date Final Inspection by(---O Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 368-3821 ❑ 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 FEE AMOUNT DUE 1 AMOUNT REMITTED CASH RECEIVED BY DATE P€RMIT�NO. INFO + 1REV.1/85) EH 13-25 mss, d l �, 3