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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 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 Aures and Regulations of the 5a Joaquin Local Health District. ' 1..�- ��0 4u Lot Size PM Job Address ` 0 S So�t� �`�� V City C ct n Ii .* 1pmd,% �u+<c0 I t4ddress () Soa�� t]` l Phon 3tA�b1.1' Ic51'z+O Owner's Name Ca \bLf Contractor MCC` �0. IAQQ�`t Address C C `13OE�� License No. -& Phone TYPE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ G. ) PUMP INSTALLATION C1SYSTEM REPAIR L3OTHER 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 {+ ❑ Industrialr ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'] Public ❑ Other t ❑ Delta Depth of Grout Seal Type of Grout Approx.;Depth l I Eastern Surface Seal Installed by 1 i Irrigation — I Repair Work Done ❑ Type of Pump H.P. State Work Done Weil Destruction ❑ Well Diameter Sealing Material (top 501 Depth t Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is i available within 200 feet.) I Installation will serve:'Residence�-k Commercial_ Other' Number of living units: Number of bedrooms {� Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg �= Capacity Method of Disposal No. Compartments i PKC. TREATMENT PLT. ❑ {. 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 y SEEPAGE PITS l-I Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ` r that the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application and I 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."Contractors hiring or sub contracting signature certifies the following: -4 certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman' tion compensa- tion laws of California." applicant m t call for all required ins ctio S. Complete drawing on reverse side. The app t 3 3 I .Signed Title: 'Y t Date: r FOR DEPARTMENT USE ONLY r/ M Application Accepted by Date Pit or Grout Inspection by Date 1 f=inal Inspection by 1 Additional Comments: ❑ 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 35201 r i FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT'NO. INFO . EH 1 3-241REV.1/95l 3S , oC> g EH 54-28