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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED rf (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. JA r C Job Address �/ City Lot Size PM Owner's Name '' �,�1�'.! «fl�iIa"r Address Phone Contracfor.__ r� Address -- —License-.No..aPS_ - Phone. � TYPE OF�WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ T 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 I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing. Type❑ Domestic/Private ❑ TGravel Pack ❑ Tracy YP of Casing Specifications � Cl Public Cl Other ❑ Delta Depth of Grout Sea! Type of Grout t i I I Irrigation _Approx� Depth I 1 Eastern Surface Seal installed by i Repair Work Done E-1Typeof Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'i Depth I Filler Material (Below 50') -- TYPE OF"SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION E I DESTRUCTION I I (No septic system permitted if public sewer is � available within 204 feet.l Installation will serve: Residence Commercial_ Other t ; q l: Number of living units: � Number of b drooms 3 ? � r Character of soil to a depth of 3 feet! I ? Water table depth SEPTIC TANK Ct,-Type/Mfg Capacity- 32._- No. Compartments ' PKG. TREATMENT PLT. ❑ Method of Disposal /®r r Distance to nearest: Weil orFoundation Property Line y } LEACHING LINE No. & Length of lines � 7� Tota! length/size FILTER BED ❑ Distance to nearest: Well a r Foundation 1�� r Property Line (� r SEEPAGE PITS i el-Depth Size S6 Number s D 1101 SUMPS 9 Cl Distance to nearest: Well-l" Foundation+o� t Property Line i 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 Di' trict. h �. 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 shatl not employ any person in such manner aslto become subject to workman's compensation laws of California."l 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 empl6y persons subject to workman's compensa- tion laws of California." I The applica t t call for all re ire inspections. Complete drawing on reverse side. ? Lj I t 1.. "f�� ! _ Signed X� ! Title: �'�� Date: i� FOR DEPARTMENT USE ONLY 6 Application Accepted by ,� �r • - Date �� Q Area -f -a" _ Date,, )or Grout Inspection by Date�.11 �Fina! Inspection by ate I Additional Comments: -, 2' / ❑ Stk 466-67811•,-[- Lodi-369-8621- •---0-Manteca_823-7-?W-_--:—Cl-T-racy-835-6385 [ Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton•Ave., P.O. Bax 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERM1IT'NO. +.EH 13.241REV.1/85) O 3 0},_- �� q•-JO�pO i EH 14.28 t