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a 0 -1 I � 211. �I -y , .,_ . LIAR 1 � I1984 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL-HEALTH DISTRICT SAN J0AQL11y LCCA. 1601 15: HAZEL T ON AVE.., STOCKTON, CA 14EAL `H DISTRICT Telephone {209} 466-8781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED "A-I,/,9-c A- f�0 _ (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 H compliance with San Joaquin County Ordinance No.549 for sewage_ No. 1,�2 f Voll purr an the Ries and Regu ns f the San Joaquin Local Health District ' .Ili"'•--��iii�� Job Address VA City Lot Size PM Owner's Namer Address Phone Contractor's Name icense No. / Z 3 -3 Phone L TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 PUMP INSTALLATION ❑ SYSTEM REPAIR lir OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL FLD. PROP. LINE. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications -� ❑ Public E1 Other 11 Delta Depth of Grout Seal Type of Grout rngation �pprox. Depth ❑ Eastern S ace Seal Installed by 1 ✓' Repair Work Done SType of Pump7. Se H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') tAMAl Depth ° ' Fill&-Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑' DESTRUCTION ❑ Mo septic system permitted if pubic sewer is Jl I available within'200 feet.) o Installation will serve:-,Residence_ Commercial_ Other s` Number of living units: .Number of bedrooms Character of soil to a depth of 3 feet: t Water table depth s SEPTIC TANK ❑ T e/Mf h yP 9 Capacity No. Compartments 4 `. PKG. TREATMENT PLT, ❑ • Method of Disposal , Distance to nearest: Well Foundation Property Line_ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line t `_ DISPOSAL PONDS ❑ 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 nner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies t following:"I carti that in the perfo mance of work for which this permit is issued,I shall employ persons subject to workman's compensa- tion law of California " The app icant must c it f required s ted wing on reverse side. Signed 1 v`d` Title: Date: FOR DEPA TMENT USE ONLY rn Application Accepted by v — Date L g • Area Pit or Grout Inspection by Date Final Inspection by I& Date 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 CK CASH RECEIVED BY DATE PERMIT'NO. +EH 13.24{REV, 101831 EH 1428 ` ��gLi �J�--)—Cl( 1 �!