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' 1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 the San Joa in Local Health District. Job Address City Lot Size PM Owner's Name 0 I r Address _ �, Phone P � ,I ++�� O i ContracVGt5 � AddresSGP.� ,3 +�lj/ a 004weicense No. 7 I4b 74) Phone —S i TYPE'OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER '1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE << i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 1� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION_ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ti Dia. of Well Casing R ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications� [l Public :Other 71 Delta Depth of Grout Sealt�W d Type of Grout ,F�"� - I I Irrigation —.Approx..(Depth I I Eastern Surface Seal Installed by Repair Work Done 1-1Type of Pump•I H.P. State Work Done _ :r Weil D�traction ❑ Well Diameter Sealing Material (top 50') lkit t _b ) Depth Filler Material (Below 50'I TYPE= OF SEPTIC WOR :—NEW INSTALLATION 1.1 REPAIR/ADDITION l 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other ` Number of living units: Number of bedrooms Character of soil to a depth of 3 feet-'I Water table depth SEPTIC TANK- .❑ Type/Mfg) Capacity No, Compartments PKG. TREATMENT PLT. ❑ � _ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Len gth of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1l Depth I Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ Y 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, 1 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 mu 11 for I req I Complete drawing oA rev rse side. Signed Title:. �/e..j 4cj Date: FOR DEPARTMENT USE ONLY Application Accepted by �� Dai Area Q Pit or Grout Inspectio by Date _Final Inspection by Date/ A7 Additional Comments S � /� 44 l� S 40 ❑ Stk 466-6781 ❑ Lodi'-369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 R FEE AMOUNT DUE. AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO + 1 13-241REV.1/85: [ r r�103