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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �b 4uj ��K 4 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 �e r (PERMIT EXPIRES 1 YEAR FROM DATE ISSUED UQ , ,1 + a ! (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.`_ Job Address ... ` City of Size X lea PM Owner's Name k Address T Y phone IN # `� S 9 Contractor dr s' = License No. -Phon ti TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �} PUMPANSTALIATION-❑—�Ii_--- SYSTEM-REPAIR"❑ OTHER'❑'"`""" "`� DISTANCE TO NEAREST: SEPTIC TANK; SEWER LINES DISPOSAL FLD. PROP. LINE 1_ ( FOUNDATION, AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA i CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing LlDomestic/Private ❑ Gravel Pack E] Tracy Type of,Casing Specifications C1 Public ElOther LJ Delta Depth of Grout Seal Type of Grout 1�'1 ❑ 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— Depth top 5U'I Depth Filler Material igelow 50 } TYPE OF SEPTIC WORK: NEW4INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r r available within 200 feet.) Installation will serve: Residence Commercial_ Other v r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I = Water table depth SEPTIC TANK ❑ Type/Mfg I r Capacity No. Compartments PKG. TREATMENT PLT. j�� ' � Method of Disposal 1 Distance to nearest: Well Foundation Property Line LEACHING LINE 3 ❑ No.-& Length`of lines Total length/size f. FILTER BED ❑ Distance to 4'arest: Well Foundation 'Property Line r " " °"'. "rte'"_'"" x' _"v """'•_ SEEPAGE PITS ❑ Depth Size Number 1 SUMPS ❑.,, Distance to merest: Well 'Foundation Property Line r DISPOSAL PONDS ❑ 4 J I Hereby certify that i have prepared this dpplieation 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. Si 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 M 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." The applican must call for al required in k� ctions. Complete drawing on reverse side. I t E Sigt Title: Date: 45 } i FOR EPARTMENT USE ONLY Application Accep id by Date i Areas Pit or Grout Inspection by Date Final Inspection bDatea Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621'L ❑ Manteca. 823_7104 .,Tracy -.639 ,-,Applicant- Return`611170—pies.'toEnvironmental Health Permit/Services 1601-E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 M INFAMOUNT DUE AMOUNT REMITTED CAS O H RECEIVED BY DATE PERMIT*NO. + EH 13-20(REV.i/85) °`tib C, - - £H 14-28 (2l -� g� ��g�3