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APPLICATION FOR PERMIT �. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA - Telephone (209) 466-6781 PERMIT EXPIRES 7 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 Sari Joaquin County Ordinance Nu:'549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. r � Job Address �� I .d City., _�T%�Lot Size' 6�M Owner's Name - Address Phone J1yq /C� w License No. old J '. _Phone "Coritractor Atldress'�- 6'� " TYPE.OF WELL/PUMP! _YNEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' \ `PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t-• ) DISTANCE TO NEAREST:'SEPTIC TANK ; SEWER LINES DISPOSAL FLD. E PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ } INTENDED'USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t r ❑ industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private ❑'Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ..0-Other.. i ❑ Delta Depth of Grout-Seal Type of Grout �_ �.`. ...4a ( 11 irrigation �Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑, ;Type of Pu' r ,H.P. State•Work-Done Well Destruction ,{ ❑" Weil:Diameter Sealing Material (top 50') ! I1 Depth 1 Filler Material Teiow 50'1 , a :.8 TYPE OF SEPTIC WORKNEW'i 4 STALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is r 1 L<1 // available within 200 feet./ E Installation will serve: Residence J�H Commercial Other t tt F 7 t F �� ? Number of living units:, .• - Number of bedrooms ._ I f Water table;depth t I Character of sofltto a depth of 3 feet: .5Ary ` p "6EPTIC,TATs K ff'f ❑# ,Type`Mfg p� �j Capacity_ /J� No. Compartments PKG. TREATMENT PLT. ❑ I �„� q t Method of Disposal E' G Distance to nearest: Well — Foundation - t Pro # perty Line-4E • .tai len th/sizes LEACHING LINE j❑� ;No. & Length of lines '- '� ` 19_ .FILTER BED I Distance to nearest: Well `Q.��Foundation Property Lin e SEEPAGE PITS �y„i`C7 Depth a Size Number (� SUMPS ❑ * Distance to.nearest:, Well Foundation. Property Line. (`�7 DISPOSAL PONDS__ ❑ hereby certify that.l:have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and C rules and regulations of the San Joaquin Local Health District. I Home owner or licensed agent's signature certifies the following: "/.certify that in the performance of the work for which this permit is issued, I shall not employ any person in-such rrlanner 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." i v The applicant must call fry allr uired ins ctions: Complete drawing on reverse side. i Title: Date: Signed X � rr sf'+ / PART ENT USE ONLY J / - Application Accepted by 4 Date Area / } l ` ! Pit'or Grout Inspection by Date„a Final Inspection by Date 3 Additional Comments:- t' ❑ Stk 466-6781 ❑ Lodi' 369-3621 ❑-Manteca 823-7104 ❑ Tracy 835-6385 i Applicant-'Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,,.P.O. Box 2009, Stk., CA 95201 $ FEE, - �-•CK �--- --r-�-_-_-•..---•-•.---w,-.�.- i INFO AMOUNT DUE AMOUNT REINIT ffD,. CASH RECEIVEL]BY /]ATE-.� PERMIT�NO. t - - T- + EH 13-24 MEV.1/85) EH 14-28