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Y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTV 1601 E. HAZETON AVE., STOCKTON, CA % EC Telephone (209) 466-6781 { JUN 2 2 i9g0 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIRONMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work h rPERMIT/SERVICES Rd scribed. 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. Job Address Agq.00 -S,6 4CA City Lot Size PM Owner's Name Address Phone C Contractorddressla � �U ense No. �o� Phone �J120 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ I 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 M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _-.Approx. Depth I I Eastern ,/Surface Seal Installed by i Repair Work Done (�Type of Pump 1. H.P. G�` State WorkDone. Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence— Commercial— Other { Number of living units: Number of bedrooms 0 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �1 KG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line , ' LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line t _ b , SEEPAGE PITS I I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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-"Contrattot'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.sha"II employ persons subject to workman's compensa- tion laws of California." The applicant mu cal f all requid inspections. Complete drawing on i&everse sides s Signed X Title: Date: � � R DEPARTMENT USE ONLYJr Application Accepted by Date Area Pit or Grout Inspection y b '` Date Final Inspection by Date 3 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. I +,EH 13-24 4REV,i i H 5) t S EH 14-28 0