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r APPLICATION FOR PERMIT . SAN JOAQUIN LOCAL HEALTH DISTRICT ` 1601 E.�HAZEL-TON AVE., STOCKTON, CA Telephone (209) 466-6781 Ahr 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 Ryles and Regulations of the San Joaquin Local Health District. i Job Address "- Fo '�: .' ' �5':1 F J P City T IC Lot Size ��X ( 4 O PM Owner's Name A 0-7- Address:4 S Pi'uvL G: Phone 6 Contractor�,}Li ? M15- . Tge-i Address �;0. 906 5 2-b License No. 33.4-31 9 Phone -4fJ A - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEA EPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUND AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom 1-1 Manteca Dia. o ation' _ Dia. of Well Casing } ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy' i Type of Casing Specifications ❑ Public ❑ Other ❑ Delta€ Depth of Grout Seal _ of Grout i 4 ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P: State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'1 ' Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence— CommercialOther Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 4 Water table depth.- SEPTIC epth- SEPTIC TANK ❑ Type/Mfg Capacity - 1 No. Compartments PKG. TREATMENT PLT. El ° -� ° Method of DisposalAOn Distance to nearest: Well Foundation t T;�Property Line. r LEACHING LINE ❑ No. & Length of-lines A`° ' J�Total-length/size FILTER BED ❑ Distance to nearest: Well Foundation I Property Line t SEEPAGE PITS ❑ Depth SizeNumber - - -' k SUMPS ❑ Distance to nearest: Weh Foundation Property Line a f DISPOSAL PONDS' ❑ J 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. 1 i 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.",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 The applica ust call for all required inspections. C mplate drawing on reverse side. l Signed ``-Z Title: Date: {�= FO DEPARTM NT USE ONLY Application Accepted by' 9y Date "2 - Area i Pit or Grout Inspection Date ~� f Final Inspection by - Date i w 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 95201FEE d „. INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY ///DATE PERMIT`NO. +EH 13-24(REV.1/95) EH W26