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t APPLICATION FOR PERMIT + SAN JOAO:UIN LOCAL HEALTH DISTRICT ' f 1601 E. HAZELT ON AVE., STOCKTON, CA Telephone (209) 466-6* Y PERMIT EXPIRES 1 YEAR-FROM DATE ISSUED ' y _ (Complete in Triplicate) � f, . . ;� .• Wit..;, - 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 the4Ryles and Regulations of the San Joaquin II[{ Local Health District. ' Et Y Vii: } i. F •- gg � �- Job Address ® City: "Lot Size�� - PM r ,. Phone P Owner's Name= i' Address k Contractor Address &&_V_0L License No —Phone "STYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 4 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 CONSTRUCTION SPECIFICATIONS f ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑.Gravel Pack El Tracy Type of Casing Specifications ' i ❑ Public ❑;Other ❑ Delta Depth of Grout Seal Type of Grout k ❑ Irrigation �Lpprox Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done t Well Destruction ❑ Well Diameter Sealing Material (top 50'1 r Depth L Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ESTRUCTION ❑ .(No septic system permitted if public sewer is N f available within 200 feet.) i t ... Installation will serve:- Residence_ Commercial Other F � ~ ' Number of Irving units� .: - Number of bedrooms Character of soil to a depth of 3 feet: 0114te Water table depth ^� a SEPTIC TANK ❑ Type/Mfg Capacity No Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r S LEACHING LINE ❑" No. & Length of lines �` k Total length/size (/ r J" FILTER BED ❑` Distance to nearest: Well_eo-'O 0-t_ Foundation /0 'Property Line SEEPAGE PITS Depth - Size Number LL + SUMPS ; _ .., ;0;1 Distance to nearest: Well ��A, Foundation _- Property Line '_ w r 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, an rules and regulations of the'San Joaquin Local Health District. 4 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 compehsa- tion laws of California." The applica call for II re r d inspections. Complete drawing on reverse ide. - j Signed Title: Date: • FOR DEPARTMENUSE ONLY.- T ' Application A epted by - Date -�`S� Area Pit or Grout Inspection by ate Final i spection by Date A u' A. )tional Comments: fi�5tk 466 6781 ❑#1 , 9-3621 ❑ M taco 823-7104 ❑ Tracy 835-636ri Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. 8Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE # PERMM"NO. INFO +EH13-241REV.1/65) EH 14-28 ��•. ` - t ,