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-APPLICATION FOR PERMIT ' I SAN JOAQ.U.IN LOCAL HEALTH DISTRICT 1601 E. "HAZE"TON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES 7 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District,f9r a permit to construct and/or install the work herein described.TMs application is made in compliance with San Joaquin County Ordinance NA.549 for-sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin ' Local Health District. _ 1 Job Address o2 Z F3 7SG�1 i&,9 ,��'� City Q ,4^1 e,—_4ot Size�'Ad PM Owner's Name�-Tlp 7 / -� Address 42a Z AZY '1 5:F re t4 Phone,6 Contractor's Name r 4f r� _ f' License No. Phone TYPE OF WELOPUIVV NEW WELL ❑ WELL.REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' 1 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications r ❑ Public ❑ Other El 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 Work Done �V Well Destruction Cl Well Diameter Sealing Material Stop 501 l th Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW NSTALLATION ❑ REPAIR/ADDITION ❑ 'DESTRUCTIO (No septic system permitted if public sewer is available within 200 feet.) Insta i serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 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 SEEPAGE PITS ❑ 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 work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. r C 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." r. The applicant must call for all required inspections. Compkete drawing on reveirse side. Signed X6.r z�e Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Z Z a Area Pit or Grout Inspection by f 1A, Date Final Inspection by Date�� ' Ik 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 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO." + Ei13-24(REV.10/83) zip_ -1-77 EH 14-25 O