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' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT • 1601 E. HAZELTON AVE., STOCKTON, CA ` Telephone (209)'466-16781 PERMIT EXPIRES 'I YEAR.FROM 'DATE ISSUED " �7 (Complete in Triplicate) Application is hereby made to the San Joagwn 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. If I X �VU I Job Address i �• City k-) Lot Size o&5 PM s i Owner's Name AddressG , -- - Phone Contractor's Namelk�� License No. LLLQ/3 - Phone TYPE OF WELL/PUMP: 41 NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REP OTHER ❑ DISTANCE TO NEAREST: SEPTiC TANK 5�/;= SEWER LINES 47-DISPOSAL FLDL-0_Q/ PROP.-LINE—/ I' I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION ❑ Industrial ❑ Open Bottom ❑ Manteca Dia: of Well Excavation Dia. of Well Casing IvDomestic/Private *-travel Pack ❑ Tracy Type of Casing Specifications {� Ll ❑ Other ❑ Delta Depth of Grout Seal �][L� Type of ut El Irrigation --Approx. Depth L1 Eastern Surface Seal Installed by r f Repair Work Done ❑ Type of Pumps 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 ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence,11 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.1 • Capacity No. Compartments `l PKG. TREATMENT PLT. ❑ 1 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 Pra a Lin -j I p � e SEEPAGE PITS ❑ Depth ISize Number SUMPS ❑ Distance to nearest: Well = - — : �-� —t Foundation Property Line 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 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,I shall employ persons subject to workman's compensa- tion laws of California." t The applicant ust call for all Tqu' d inspections. Co plate drawing o reverse e. r Signed Title: Date: �11,02Y It OR PA MENT USE ONLY Application Accepted by Data Area_ [� Pit or.Grout Inspection by Date �(C?:r�'rincl Inspection by pate (0 Additional Comments: ❑ Stk 466-6781 . ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE L G7 LAN �h4� INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. + NF1 13.24(REV.10/83) EH 14.26 � . t7Q