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F l APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE 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 Rules and Regulations of the San Joaquin I Local Health District. i / 9,0 U / S �AFL. dA-7%'k 0' City a t Lot Size PM Job Address � ,.�.,I ool S Q7�C ajO'7%4 ' Phone f a 7 � f Owner's Name ✓�e � 1-0*41 Address {� Contractor's Name License No. Phone 1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i 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 ❑ Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications .1 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —_Approx. Depth ❑ Eastern Surface Seal Installed by 1�3 Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units:,_',I - Number of bedrooms c : ' . Character of soil to a depth of 3 feet: Water table depth 4 SEPTIC TANK ❑ Type/Mfg ' < Capacity No. Compartments i 71 PKG. TREATMENT PLT. ❑ N w Method of Disposal { Distance to nearest: Well Foundation {'• Property-Line- - Y LEACHING LINE ❑ No. & Length of lines 7P IF Total length/size 6y. I FILTERTBED ❑ Distance to nearest: Well/mQ Foundation 101 Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance!to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ rt 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 I rules and regulations of the San Joaquin Local Health District. 41 -' 3�- '. . Home owner or licensed agent's signature certifies the following: "I certify that in the performance of"te work for which-tliis 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 endo`persons subject t6-workman's compensa- tion laws of California." E The applicant must II for II required_-inspectio�ns.-Complete drawing on.reverse side. Signed X �� `� Title: FOR DEPTMENT-USE ONLY Application Accepted by Date '! Area Pit or Grout Inspection by �{ Date Final tnspection by Date �• Additional Comments: -•- ❑ Stk 466-6781 El Lodi 369-3621 El Manteca 823-7104 ❑ Tracy 835-63135 i- r Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ' 1 ' FEE 1-4—�INFO� °`MOUiVT DUE AMOUNT REMITTED�4 +� y .RECEIVED BY,�"�. a j DATE PERMIT"NO. + E'142'4(REV.10/83) 1 d "LAs - Zs /Z�{/ -as