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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT r. 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED f elephoile (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDAUG 1 _ 1983 1- 1, (Complete in Triplicate) ENVIRONMENTAL_ Fi ., r Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install th is application is made in compliance with San Joaquin County Ordinance No.'549 for sewage or No. 1862 for well/pump and thl u lruwI sof the San Joaquin Local Health District. Job Address ` 2N L ..�r-V* I City Lot Size PM f J �I f Owner's Name fl J Address Phone 23` 0 I`. rr�� r! Contractor' Addfessj II wt,., License No.� �2t5 Phone TYPE OF WELL/PUMP: NEW WELL ❑ f WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ N SYSTEM REPAIR ❑ OTHER EK { DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — . 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. bf Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracyi Type of Casing Specifications ['1 Public Ll Other ❑ Deltall Depth of Grout Seal Type of Grout — f i I Irrigation Approx. Depth` [ I Eastern Surface Seal Installed by _ Repair Work Done VL Type of Pump __.. H.P, j State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 — R 1 I Depth 'Filler Material 18elow 50'1. TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION [ I DESTRUCTION l 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 11 Character of soil to a depth of 3 feet: �M' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I�' Method of Disposal Distance to nearest: Well Foundation Property Line :� I LEACHING LINE ❑ No. & Length of lines � Total length/size i I. FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line _ '�"-"'�-DISPOSAL PONDS — ❑ I hereby certify that I have prepared this application and that-the-v4ork 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 3 employ any person in such manner as to become subject toWorkman's compensation laws of California." Contractor's hiring or sub-contracting signature 1 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." .IN! II The applicant must call for all required inspections. Complete drawing on re rso side. Signed X � - t 1_ �--- II Title: __ Date: j011f DEPARTMENT USE ONLY Application Accepted by / ml !!!� Date Area Pit or Grout Inspection by Date Final Inspection bv�� DateO d Additional Comments: I� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i I INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT NO. +.EH 13.241REV.1/"5) 3 EH 14-26