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F ' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL i ON AVE., STOCKTON, CA oQ Telephone (209) 466-6781 CJ`s PERMIT EXPIRES 1 YEAR FROM DATE ISSUED G� (Complete in Triplicate) V 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 N10 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1852 for well/pump and the Rules and.Regulations of the San Joaquin Local Health District. Job Address City 57A:�i✓ Lot Size PM Owner's Name 01204 AZZLL/.4,95 Address --i-4voVE Phone Contractor's NameFG�'f25 �ll�� License No. Phone 7 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 {Belo 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 2T DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence'/ Commercial_ Other Number of living units: Number of bedrooms -3 Character of soil to a depth of 3 feet:. Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PL7. ❑ __ _ Method of Disposal Distance to nearest: Well Foundation Property Line ` LEACHING LINE No. & Length of lines I/— to X I Total length/size iX Z FILTER BED 11 Distance to nearest: Well A) Foundation '30 Property Line_ /0 P SEEPAGE PITS Depth —I—S" Size 'J Number SUMPS ❑ Distance to nearest: Well 0_. Foundation VA Property Line DISPOSAL PONDS ❑ 1 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 subcontracting 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." The applicant must call for all required inspection . Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY .t Application Accepted byDate C— Area d T Pit or Grout Inspection by .x w �3'��Final_Inspection by 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 CASH RECEIVED BY DATE PERMIT"N0. +EH 13.24(REV.10/83) EH W28 J