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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 Z 1601 E. HAZE T ON AVE., STOCKTON, CA V� Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED (Complete in Triplicate) . ;y KDt<.rUIN LOCAL Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein deserib�d. Tls a�p�icatib7t-iso 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, Job Address 7l 7f /Y 1/ City Loi Size PM h Owner's Name !CJ/9?-___7_LD` r� Address Phone Contractor's Name License No. Phone 4 TYPE OF WELL/-PUMP: - NEW WELL ❑ WELL REPLACEMENT-0 DESTRUCTION ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ - :'DISTAN CE'TO-NEAR EST: SEPTIC-TANK--- """"' "SEWER LINES""' v'DISPOSAL'FLDPROP�-LINE— i 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 i ❑ Domestic/Private ❑-Gravel Pack ❑ Tracy Type of Casing Specifications E ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by ~ Repair Work Done ❑ Type of'Purnp- - H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material hop 50') Depth Filler Material (Below TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION-PR-Jo septic system permitted if public sewer is s " Y vailable within 200 feet.) Installation will serve: Residence_ Commercial_ Other, k Number of living units:. Number of bedrooms Character of soil to a depth of 3 feet: f' Water.table depth t v+w SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 1:1- _�• k Method of Disposal * n Distance to nearest: Well 'Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total lengthlsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line _SEEPAGE PITS .�_ __.❑ Depth Size_ Number SUMPS ❑ Distance to nearest: -,Well Foundation Property Line i 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 i 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 at call for all required inspect( ns. Complete drawing on reverse side. i SignedX �'1_/IJY t��P� Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection 15y Date Final Inspection by Date Addition I Comments: 11� ` , 1� I ❑ Stk 6781 ❑ Lodi 369-3621 ❑ Manteca 823-7 ❑ Tracy 635-6385 Applicant\\Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P'.O. Box 2009, Stk., CA 95201 INFO - AMOUNT DUE AMOUNT REMITTED CA6H RECEIVED BY DATE PERMIT'NO.' + EH 13-24(REV.10/83) . EH 14-26