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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA t Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) and/or install Application is he+eby made to the San Joaquin Local Health District for a permit to construct the work herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District.- Al U Aid City Six � Lot Size !�X PM Job Address t, Address � /U. U Phone 9's<f r7 Owner's Name _�uaYD LJ&C Address Af � �,� ��` License Na �7�S�7L Phone i Contractor DESTRUCTION ❑ TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ + " STEM REPAIR Ll OTHER ❑ PUMP INSTALLATION ❑ SY i SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL— PROBLEM INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS❑ Open Bottom Dia. of Well Casing ❑ Manteca Dia. of Well Excavation , ❑ industrial 4 TSpecifications ❑ Domesticl Private ❑ Gravel Pack ❑ Tracy Type of Casing IType o1 Grout f`] Public ❑ Other ❑ Delta Depth of Grout Seal Approx. Depth l l Eastern Surtace Seal installed by I Irrigation '— , r State Work Done Repair Work Done ❑ Type of Pump H P i Well Destruction ❑ Wel! Diameter Sealing Material (top 501 Depth tL Filler Material (Below 501 TYPE OF SEPTIC WORK: 'NEW INSTALLATION i.l REPAIRIADQITION QESTRUCTION t 1 aNailableseptic withiin'2t000 feetftted if public sewer is Installation will serve: Residence Commercial Other A.4WAf/� Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet. ��. 00 No. Compartments Z SEPTIC TANK ❑ Type/Mfg P�'L" Capacity��-- ` Method of Disposal 4 PKG: TREATMENT PLT:❑ #to nearest: Well I _ Property Line-2-W Distance �l'�_ Foundation r. g ' }- Total iength/size LEACHING LINE ❑ No. & Length of lines Property Line FILTER BED ' ❑ Distanc.J to nearest: Well Foundation I I Depth I Size Number SEEPAGE PITS ;, Property Line SUMPS ❑ Distance to nearest: Well Foundation 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 Id rules and regulations of the San Joaquin Local Health Di§trict. 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 signature shall not employ any person in such manner as to become subject to workman's compensation taws of California." Contrace�sons�sub ect to wo km n'sring or gcompensa- ' certifies the following: "I certify that iri the performance of the work for which this permit is issued, I shall employ P t :tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. ^7 Title: Date: 9T �, -?2 Signed X OR DEPARTMENT USE ONLY 1 Date Area�! Application Accepted by Pit or Grout Inspection by Date Final inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy B35-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,IP.O. Box 2009, Stk., CA 95201 x FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED By DATE PERMIT NO. INFO +.EH 1324 IREV.1/85) EH 44-26