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APPLICATION FOR PERMIT v ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-Ml PERMIT EXPIRES I 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 descnbed. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 18K for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 14 I, {� 1 (1(� ,��, Job Address �d� `t"'t � 1'1\C- �)o( \� W City_1!ya!-AC—CA Lot Size PM Owner's Name 1 L d �OL•��Y�(1 IJ ICdd S � ►�� S. ABC-PtA Phone q Contractor_ �� Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ 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 —Approx. Depth ❑ Easter Surface Seal InstaN@d by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if.public scorer is r 1 -vvailable within 200 feet.) �/ Installation will serve: Residence� Commercial Other t— Number of living units: �— Number of bedrooms�; E Character of soil to a depth of 3 feet: sQr,du Water table depth SEPTIC TANK �< Type/Mfg Capacity 1 No. Compartments PKG. TREATMENT PLT. ❑ 7 / •� Method of Disposal Distance to nearest: Well Foundation Property Line ,�0- LEACHING LINE No. & Length of lines ozeln " 7.5 Total length/size IS FILTER BED ❑ Distance to nearest: Well qd" Foundation I Ll - Property Line SEEPAGE PITS ❑ Depth Size Number V SUMPS ❑ Distance to nearest: Well Foundation Property Line.__ DISPOSAL PONDS ❑ X 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 sgnature certfes 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 appl• must call for all re 'red inspections. Complete drawtnTil5terse side. !p X Signed -- Title: Date: y� ,� FOR DEPA MENT USE ONLY (� Application Accepted by �S` '�' 1 �� Date `' Area VU Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356386 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED fl RECEIVED BY DATE PERMIT'NO. INFO � EH 13-241REV.1/85) 17O lo'3 -800 -WIN EH 1128 i