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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT F 1601 E. HAZEL T ON !A VE., STOCKTON, CA _ Telephone X209) 466-6781 ff PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E� 1 I (CompleteMin Triplicate) 114AY 89 Application is hereby made to the San Joaquin Local Health District for-a permit to construct and/or install the workherein described.TThis application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the RuV6S'aAd.Regulations.of the San Joaquin i� r19A'._ :., `._ j.:. -1 it Local Health District. •!� ��`� �.. 4r_f�,Lr,�,:^t�7;'t 1li U"� Job Address 3 3r ^ Cit Lot Size PM Owner's Name 7r,.0Address �� A6 � _ Phone Contractor PR&S-7Elk< Address UO A 9dDk&A&W Lscense NoA,7 I ?4o -Phone 36 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LIN ES 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 K Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications F Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout I 1 Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump l H.P. Q State Work Done I S r Well Destruction ❑ Well Diameter Sealing Material (top 50') w Depth Filler Material (Below 501 Vj TYPE OF SEPTIC WORK: NEW INSTALLATION I-I REPAIR/ADDITION l I DESTRUCTION I I lNo septic system permitted if public sewer is y� available within 200 feet.) "l Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms yhy Character of soil to a depth of 3 feet: I! Water table depth SEPTIC TANK ❑ Type/Mfg k Capacity No. Compartments 4 PKG. TREATMENT PLT. ❑ Method of Disposal 11 r Distance to nearest: Well Foundation Property Line I 4 LEACHING LINE ❑ No. & Length of lines I Total length/size FILTER BED ❑ Distance to nearest: Well [Foundation Property Line ; I , SEEPAGE PITS i I Depth Size 'M Number SUMPS ❑ Distance to nearest: Well '[Foundation Property Line DISPOSAL PONDS ❑ 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 Diiltrict. II 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: "l 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." i I The applicant st call all required inspections. Complete drawing ori reverse side. g Signed X Title: , .�� Date: IM , FORPEP TPIENT USE 014LY i g Application Accepted by Date / Area i Pit or Grout Inspection by Date I� Final Inspection by Date Additional Comments: II ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE; PERMIT'NO. j +.EH1324(REV.1 i 8 s) S EH 44-29 / ,� 7