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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT . 1.; 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAWFROWDATE 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 Roles and Regulations of the San Joaquin Local Health District. Job Address _&[O �«� � � t r "_ City E tot Si e1 ` } PM s. Owner's Name 6— Address �tS.�2y , T Phone Contractor Address& t 1cense No. Phone?_ 0Jb' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _ OTHERgEr r 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 CONSTA.RUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of;Well Excavation Dia. of Well Casing ,a'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 _.44o{L H.P. f r StaW Work Done Well Destruction ❑ Well Diameter Sealing Material Ito' 501 Depth Filler Material (Below 561 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_ Commercial— Other ! Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC-TANK ElType/Mfg I Capacity ` `� ' •liTNo. Compartments i h,► I PKG. TREATMENT PLT. Cl I Method of Disposal Distance_to nearest: Well Foundation Property Line \ LtAtHING ILINE TM t❑ 'No. & Length of,lines" -Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑- Depth Size # Number 1 47 _SUMPS `SUMPSDistance—to—nearest: —Well _ Foundation_ Property Line - _r 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 com*,en°a- tion laws of California." The applicant m st all for all required inspections. Complete drawing on rev a side. Signed Title: R DEPARTMENT USE ONLY .. r�r Application Accepted 7 ` Date rea ms M 1— d Pit or Grout Inspecti y Date 1� Final Insplection by 'Dat �� Additional Comments:7�c� CC C U, ,it )130LMe ls.(U° { ,4 rrt t7, r c�fri i ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 [] Tracy Applicant- Return all copies to: Environmental Health Permit/Services i601 E. Hazelton Ave., P.O. Box 2009, Stk., Gr f FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. INFO 1fF I EM 14-213IREV.s/95) 3S. �O 5�g — �0� 1/ p