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i S, APPLICATION FOR PERMIT SAN JOAQUIN LOCAL.HEALTH DISTRICT 1601 E. HAZE I ON AVE., STOCKTON, CA Telephone 1120911_1466-6781 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 q 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. , �� JJob Address � �� Ci Lot Size PM Owner's Name Address y�� "' Phone i �1�.., tt11 32� 2 3 el ' Contractor �� Address /] � fi License No.T�r Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 'PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ r OTHER 4 O DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL FLD: t - "` 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 e Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ^ ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump. H.P. State or Dorie Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth I Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence_� Commercial_ Other Number of living units: Number of bedrooms ol Character of soil to a depth of 3_feet Water table depth SEPTIC TANK ❑ Type/M g..., Capacity No. Compartments _ F PKG. TREATMENT PLT. ❑ 1 y 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 # SEEPAGE PITS ❑ Depth + Size Number _ r _ SUMPS ❑ Distance'to nearest: -Well'— Foundation Property Line 2.. 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 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: "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/ ust call for all r�uirred inspections. Complete drawing on rev side. /� f /r/' l it ✓ Date: 16 Y Q�-� Signed X_. Title: !ll� , c FOR DEPARTMENT USE ONLY CApplication Accepted by III Date ` (` f Area Pit or Grout Inspection by Date Final Inspection by C2 Date Additional Comments: } i CJ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 85 Applicant- Return all copies to: Enviroi mental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 1 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"N0. INFO f� CASH + EH 13-24(REV.1/85) !, �' �� ' EH 14-28 ✓..