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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. .5,pl1~ Ak- erg j Job Address 115-2-0 MiLC `4� � City V Lot Size PM I Owner's Name Vv, 4-EON hwi-4/ Address Phone t Contractor's Name 6`I'_ ©Uu� t 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 LT Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public " ❑ Other ❑ Delta Depth of Grout Seal_ Type of Grout 11Irrigation ---Approx. Depth E] Eastern Surface Seal Installed by"f ' Repair Work Done ❑.Type_of Pump_ _k.P. State Work Done Well Destruction ❑ Well Diameter ti Sealing.Material.1top•501 , — --- - - Depth Filler Material.IBeI'ovd5O'.L TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewe available within 200 feet.) Installation will serve: Residence— Commercial_ Other"�Y1Gfiil. (NDJ►g PAS Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth f SEPTIC TANK 4 Type/Mfg T6Chkkel7E CapacityP-W 6AL No. Compartments i PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Weil Foundation Property Line � I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Distance to nearest: Well IIS JJ Foundation _ Property Line_ SEEPAGE PITS ❑ Depth Size !Number � r SUMPS ft Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 v 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 applican ust c I for all required inspections. Complete drawing on reverse side, Signed Title: (z, Date: d OR DEPARTMENT USE ONLY Application Accepted Date 30 BQ Area 1 Pit or Grout Inspection y Date Final Inspection b Date Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/S4rvices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 /%A)A 1�v f CK 4 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. + EH 13-24(REY.10/83) c EH 1426 ��O Q g $` 3