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r } APPLICATION FOR PERMIT _ :J .•�° Zi' SAN JOAQUIN LOCAL HEALTH DISTRICT r} 1601 E. HAZEL 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 Local Health District. , .�— r cam, Job Address ^' City_ Lot Size-_`4® 1�� sPM 2 Owner's Name Address2ke c1 Phone ` V AZI Contractor Address_ License No. Phone 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 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 `❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑.Public ❑ Other ❑-Delta- Depth.of Grout.Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State_Work Done Well Destruction ❑ Well Diameter Sealing Material.(top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ANo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_. Commercial-= Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: '" Water table depth SEPTIC TANK ❑ ,Type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line t' LEACHING LINE ❑ No. &Length of lines Total length/size .. FILTER BED ❑" Distance to nearest: Well Foundation Property Line r SEEPAGE PITS ❑ Depth Size 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 District: Home owner or licensed agent's signature certifies the following: 'T certifythat 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,.)shall employ persons subject to workman's compensa- tion laws of California." The apps nt mu call for r e 'ns ctions. Complete drawing on reverse side. Signed Title_, <- Date: FOR DEPARTMENT USE ONLY t p� Application Accepted by " •'Date -(�,t� '` p� Area �o� Pit or Grout Inspection by Date Final Inspection by Date 9A ditional Comments: Stk 466-6781 ❑ Lodi 369-3621 11 Manteca 823-7104 0,Tracy 835-6385 A plicant-:Return all copies to: Environmental Health Permit/Services 1601 E. Haielton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED _ C RECEIVED BY DATE ,PERMIT`NO. f + EH 13-24 EH 14-26(REV.1/95) �(0�