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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i 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 Ci Lot Size PM Af 0� er s , VnZ4 Address _ Phone.2_3 Contractor's Name fa/ rin4l License No. s'•S r � Phone 0 TYPE,OF.WELLLPUMP:__.,� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK r SEWER'LINES DISPOSAL FLD. PROP. LINE 7 FOUNDATION !+ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL I 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 __4pprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump I H.PA State Work Done (J� Well Destructiori i. e❑ Well Diameter Sealing Material atop 501 }} Depth Filler,Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION DESTRUCTION 11 (No septic system permitted if public sewer is % - - /available within 200 feet.) Installation will serve: Rest encs r Commercial_ Other Number of livi g units, " Number of-bedrooms Character of-soil to a deptK'bf 3 feet: SCu t Water table depth 0 SEPTIC TANK ❑ Type/Mfg - Capacity No. Compartments PKG. TREATMENT PLT. ❑ it wS Method of Disposal f Distance to nearest: Well Foundation Property Line i LEACHING LINE I _ No. & Length of lines A — 6,0. - Total length/size X a FILTER BED ❑ Distance to nearest: Well Foundation /0 t Property Line r ! SEEPAGE PITS ❑ Depth Size { Number = SUMPS ❑ Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ I 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. I ` -t Home owner or licensed agent's signature certifies the following: 'al 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." The applicant must call fa all req ' In t• ns. Complete dra> ing on reverse side. t r Signed �w+/ Title: Date: I t FOR DEPARTMENT USE ONLY F Application Accepted by.: Date r Area Pit or Grout Inspection by Date Final Inspection b Date r I Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3821 Q Manteca 823-7104 D Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201' FEE LAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. INFO _ CASH , + EH 1426 1REV.10/83) o �k/-7/?L1 -1 ti>—L1