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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. Job Addss �`�, 6(%L -3A City Lot Size PM Owner's Name NO C*8 rr Address Phone Contractor CK° ,0y7_btV* t Sey Address License No. 'lam!°–Jr9'/ Phone TYPE OFWELL/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 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing a El Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications IC ❑ Public ❑ Other ❑ 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 fi Well Destruction ❑ Well Diameter Sealing Material (top 501 � Depth Filler Material (Below 501 1f TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION V DESTRUCTION ❑ (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: eAiYAL° A04-11 Water table depth lt'° SEPTIC TANK {IRI Type/Mfg Capacity !.?00 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well *I l Foundation IO Property Line 1 LEACHING LINE ❑ No. & Length of lines Total length/size > FILTER BED Nr Distance to nearest: Well Foundation. A- Property Line ° { SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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." The applicant must c II for all required inspections. Complete drawing on reverse side. Signed Title: Date: f-04-00, ZL= RTMENT USE ONLY Application Accepted by Date e 1pl Area—07 , Pit or Grout Inspection by Date Final Inspection by Date 14 eg Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`"N0. + EH 18-241REV.1/85) -7D Z�6 EH 14-M O0 i