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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-Ml PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 3 (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. -. Job Address CityT Lot Size PM -° �j lliz�G ?G� r/ I�✓��/ I� Address Phone Owner's Name _ - � No. Contractor iR /C7e ZI Address_k T License �0OS�� Phone y� ZI Z6/E' 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 ' FOUNDATION11 - R1CULTU14F-W. ELL —OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR013LEM-AiJ5� CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑. anM teca� Dia. of Well Excavation F Dia. of Well Casing %Li Domestic/Private ❑ Gravel'Packs Tracy - ? TYPe�'bf�Casing Specifications k ❑ Public ❑ Other ❑ Delta Depth of Grout Seal i Type of Grout — E❑ Irrigation Approx. Depth C1Easte6 Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Dane 0 Well Destruction ❑ Well Diameter Sealing Material (top 501 1 ,.] 11 17 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION (No septic system permitted if public sewer is available Within'200 feet.) Installation will serve: ResidenceFCommercial a Othef `` + ~ I Number of living units:� Number of bedrooms. r - Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK bd- Type/,Mfg Capacity No.c63mpartments PKG. TREATMENT PLT. El {/�ZI� C �/p ' Method of Disposal Distance to nearest: Well Foundation, - Property Line 4 LEACHING LINE No. & Length of lines Z Ca �� fJ�Total lengt�/size Y` Zt7 FILTER BED 134 Distance to nearest: Well ' Foundation /0 Property-L Je A SEEPAGE PITS ❑ Depth Size Number r SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Li 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./" The applicant must cR r all re uir_ed i tions. Complete drawing on reverse side. Signed i� Title- / �f` �'� Date: /--6 - - FOR DEPARTMENT USE ONLY t Application Accepted Date — Area -ry01 Dat'. �- Pit or Grout Inspection by7' ` Date Final Inspection by ., Additional Comments: °M ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy e35 8385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 , FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO { + EH 13-24(REV.F/95) ,r\G 97`- 9' EH 14-28 . ! �7• d O i