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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466_6781 PERMIT EXPIRES 1 YEAR FROM DATE 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 Rules and Regulations of the San Joaquin Local Health District. f� Job Address VFW! Aj • �j -it UTE "• FR. n (� iQhCity 5 rbQj6o o Lo �G t Size PM Owner's Name T �Fi�-f Address mr U E *B ?57—70 S6 71TYPhone Contractor's Name �� License No. �ACEMENT PE OF WELL/PUMP: NEW WELLPhone GWEL ❑ DESTRUCTION ❑ PUMP INSTALLATION 11 SYSTE RgPAIR ❑ OTHER 0DISTANCE TO NEAREST: SEPTIC TANK (26 SEWER LINES " — �• �~ I DISPOSAL FLD._y PRO., LINE FOUNDATION �— AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI S ❑ Industrial I ❑ Open Bottom ❑ Manteca Dia. of Well Excavation G Domestic/Private ❑ Gravel Pack ❑ Tracy T TIE ` Dia. of Well Casing Type of Casing S I Specifications '� ❑ Public Other ❑ Delta Depth of Grout Seal ❑ Irrigation Type of Grout ---Approx. Det ❑ Eastern Surf ce Seal Installed by Repair Work Done ❑ Type of Pump L3 H p Well Destruction 11 Well Diameter f State Work Done 3115 Sealing Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ Rl PAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is; Installation will serve: Residence available within 200 feet.) _ Commercial_ Other Number of living units: Number of bedrooms c .Character of soil-to a depth-of 3 feet: SEPTIC TANK Water table depth ' ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE / ❑ No. & Length of lines C Total Iengt4/size - . t' FILTER BED `s❑. Distance to nearest: Well Foundation yl' � ' ' ProLine SEEPAGE PITS ❑ Depth 4 Size SUMPS Number � ❑ Distance td nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that f have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state l -ter rules and regulations of the San.Joaquin Local Health District. aws, and Home owner or licensed agents signature certif` s the following: i j9 g: "I certify that in the performance of the work for which this permit is issued,;f-shall not employ any pe n in such manner ag to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the fo ing:"I certify that in the performance of the work for which this permit is issued,I shall em to tion laws of I ornia," «.. r P Y pe ns su ect to work an' c sa- The applicant st call for II equi M pectin , Complete drawing on reverse side. ` , N � Signed _ Title: '+ R ate: Z (� n FOR DEPARTMENT USE ONLY Q' 3 Application Accepted by / l`"r�'t/�LICJ Date � U { Pit or Grout Inspection by Date l re i CJ Final Inspection by Date Additional Comments: I ❑ Stk 4666781 ❑ 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 2409, Stk., CA 95201 l i FEE AMOUNT DUE AMOUNT REMITTED CK a INFO CASH RECEIVED BY DATE PERMIT"NO. c F_ x +EH 13-24(REV.10/83) EH 10-26 � U� �S Ll i