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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELION AVE., STOCKTON, CA ' Telephone (2og) 466-6781 p' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .� E ! (Complete in Triplicate) application is i County Ordinance No.549 for sewage or No. 1862 for weli/pump and the Rules and Regulations of the San Joaquin f Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described• made in compliance with San Joaquiny Local Health District:." _ t' 01111 City �p� t Lot Size PM Job Address { Phone �__ Address k Owner's Name 3��3 Af o-.-d2h-- b�' License No.go Phone Contractor �G t^ Address WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ ` SYSTEM REPAIR ❑ PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE k SEWER LINES �1 PITSISUMPS { DISTANCE TO NEAREST: SEPTIC TANK i AGRICULTURE WELL OTHER WELL— FOUNDATION'' ELL FOUNDATION'_' INTENDED USE TYPE OF WELL > PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing (� ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ` 1 ❑ Industrial Type of Casing Specifications Ll Domestic/Private El Gravel'Pack C2 Delta Depth of Grout Seal F ❑ Public Q Other { _—Ax. Depth El Eastern Surface Seal Installed by ❑ Irrigation H P State Work Done Repair Work Dane ❑ Type of Pump h Well Destruction ❑ � Well Diameter �— Sealing Material (top 50'1 l Depth Filler Material (Below 50') available within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION L) available m/DESTRLICTION ❑ (Na septic system pe rmitted it public sewer is 114.,- Other installation will serve: Residence Comrrterciai 4 rrNumber of bedrooms Water table depth Number of living units: _L__ k Character of soil to a depth of 3,4et: =c No. Compartments ❑ Typ d•Mfg Capacity— SEPTIC TANK i'< ,.F Method of Disposal PKG. TREATMENT PLT. ❑ '-foundation Property Line Distance to nearest: Well -� Total lengthlsize I LEACHING LINE Kt , No.i& Length of lines I property Line �G FILTER BED ❑ Distance to nearest: Well �� Foundation o1dation II �' . f Number 2- SEEPAGE PITS L9—Depth Size Property Line y6 0 , o ' 0�` Foundatin. -1 SUMPS ❑ Distance to nearest: Well/� -- + DISPOSAL PONDS ❑ I hereby certify that I have prepared this application aril that the w6rk wlll.beA6ne in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin Local Health District. +" x Home nwrier or licensed agent's signature certifies tfie following: '9 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 ` employ any fallowing:"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." y sl, The applicant must c I for II required inspections. Complete drawing onreverseside. GC)A)Da Date: Signed X�_ Title: _ l f J FOR DEPARTMENT USE ONLY IL Date Area A, ` Application Accepted by4 �� i Pit or Grout Inspection by Date �-- Final Inspection by Date Additional Comments:° ' - J , ❑ Stk 466-6781 D Lodi 3&9 362] ❑ Manteca 823 7104 ❑ Tracy f335-6385 Applicant Return all copies to: Environmental Health Permit/Services 1601E.Hazelton Ave:,P.O. Box 2009, Stk., CA 95201 FEE CK RECEIVED BY DATE PERMIT NO. INFO AMOUNT DUE AMOUNT REMITTED CASH - + EH 13-24 iRSV.I/95] EH 14-28 ` _