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L _ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {2091'466-6781 PERMIT EXPIRES'1'YEAR FROM DATE ISSUED r" (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. . r 41 .rte!.. 1. 3 Job Address L, 4awo !v N City, y j Lot.Size PM ' "1 Phone Owner's Name a Address�� r9 1' Contractor Address ' License No. Phone16 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ •. 1 s... PUMP INSTALLATION-O—� SYSTEM REPAIR ❑ OTHER ❑ DISTANCE To NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE V FOUNDATION AGRICULTUREWELL OTHER WELL PITS/SUMPS " 1 INTENDEDDia. of Well Casing rUSE TYPE OF.WELL PROBLEM AREA =CONSTRUCTION SPECIFICATIONS 1 1 ❑ Industrial C1 Open Bottom ❑ Manteca v Dia."of'Well Excavation ❑ Domestic/Private ❑ Gravel Pack t ❑ Tracy Type of Casing Specifications I ❑ Public ❑ Other ❑ Delta, Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by ' Repair Work Done ❑I Type of Pump i`• i H.P. State Work Done Well Destructio1n ❑' Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 4 TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION.❑ DESTRUCTION (No septic system permitted if public sewer •is } •41t' ,'' �� available within 200 feet.) Installation will serve: Residence Commercial— Other t (' Number of living units: Number of bedrooms i . Character of soil to a depth of 3 feet: Water table depth 1' SEPTIC TANK Ll Type/Mfg j Capacity No- Compartments F PKG. TREATMENT PLT. ❑ Method of Disposal E, s� —Distance to nearest:='=Well Foundation Property Line j _ - LEACHING LINE El No. &Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS EJDepth Size Number i SUMPS ❑ Distance to nearest: Well Foundation Property,Line DISPOSAL PONDS ❑ I 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. ., 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 compensa- tion laws of California." The applicantmust call for al requitred inspections: omplete draw ng on reverse si e; K. r- Date: Signed Title FOR DEPA MENT USE ONLY (/� o\ Date /Z —.Z� a Rrea Application Accepted by -T 1 ? Pit or Grout Inspection by Date Final Inspection by K ' �'_ f - w. 0 Additional Comments: ' Wtk 466-6781 .❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ` Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazeltoh Ave., P_O. Box 2009. Stk., CA 95201 p• FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO, r INFO + EH 1324(REV.1!95) 7o-"� Q. Q c7 �'!``� EH 14-28 I