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APPLICATION FOR PERMIT L� w SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA - - ' Telephone (209) 466-6781 T ` 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 h 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 3 Local Health District. �!p Cit yR at�Size I' Job Address ares _ s`fe.- QDtif ,20 Owner's Name A dress Phone I� Contractor Address License No: Phone TYPE OF (AIELL/PUIOZ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑fL PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0-. - DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL. OTHER WELL PITSISUMPS . INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t L-) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public fl Other Cl Delta Depth of Grout Seal Type of Grout ; or I I Irrigation —..Approx.,Depth 1 I Eastern Surface Seal Installed by i Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter' Sealing Material (top 501 Depth Filler Material (Below 501 h TYPE: OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION-E I DESTRUCTION -(No septic system permitted if public sewer is r r_ ( vailable within 200 feet.) Ut Installation will serve:' Residence�1 Commercial— Other � I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:; Water table depth SEPTIC TANK ❑ Type/Mfg Capacity F No. Compartments I« PKG. TREATMENT PLT. ❑ 't a yr. Method of Disposal j Distance to nearest: Well Foundation Property Line I " LEACHING LINE 171 No. length/size No. & Length of lines 9 , FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I Depth I Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 4 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. 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 applicant must call for all required lnspactlons. Complete drawing on reverse side. C !' ! Title: Date: Signed X FOR DEPARTMENT USE ONLY `rte Application AccepteAbA-- Date t c J f Are -z.a Irl t fre. S C v,.�.�.a..-, i Pit or Grout Inspection by Date Final Inspection,by `t'F c [ Additional Comments: 0 ❑ Stk 466-6781 ❑ Lodi -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 :it it FEF AMOUNT DUE, AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO / + EH13-24fREV.r/95Y 3s� �-�) -Y�i EH 14-29